MEDICARE: DR. LISA FORTUNE' SIBLEY DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	4968	LA
2	122300000X	Dentist	24962	TX
3	1223G0001X	General Practice Dentistry	24962	TX

General Provider Information

NPI Number	:	1528106176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA FORTUNE' SIBLEY DDS

Provider Business Mailing Address
First Line	:	1719 STONE TRAIL DR
Second Line	:
City	:	CEDAR HILL
State	:	TX
Zip	:	75104-3914
Country	:	US
Telephone Number	:	972-230-2012
Fax Number	:

Provider Business Practice Location Address
First Line	:	3235 W CAMP WISDOM RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75237-2605
Country	:	US
Telephone Number	:	214-414-0312
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2007
Last Update Date	:	05/11/2010

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