Healthcare Provider Details

I. General information

NPI: 1639498595
Provider Name (Legal Business Name): LISA IRISH DEESE D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 05/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 F AVE
DOUGLAS AZ
85607-1919
US

IV. Provider business mailing address

1100 F AVE
DOUGLAS AZ
85607-1919
US

V. Phone/Fax

Practice location:
  • Phone: 520-364-3285
  • Fax: 520-364-3378
Mailing address:
  • Phone: 520-364-3285
  • Fax: 520-364-4261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD009122
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN19100
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: