MEDICARE: MRS. LISELOTTE ALICE MANNION-BLACK 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	DE00007313	WA

General Provider Information

NPI Number	:	1871691600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISELOTTE ALICE MANNION-BLACK DDS

Provider Business Mailing Address
First Line	:	8400 W GAGE BLVD
Second Line	:
City	:	KENNEWICK
State	:	WA
Zip	:	99336-1075
Country	:	US
Telephone Number	:	509-735-9548
Fax Number	:	509-735-6876

Provider Business Practice Location Address
First Line	:	8400 W GAGE BLVD
Second Line	:
City	:	KENNEWICK
State	:	WA
Zip	:	99336-1075
Country	:	US
Telephone Number	:	509-735-9548
Fax Number	:	509-735-6876

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	03/23/2026

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