Healthcare Provider Details

I. General information

NPI: 1336432616
Provider Name (Legal Business Name): LISA GRAGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2011
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 E VAQUERO CT
CHULA VISTA CA
91910-8134
US

IV. Provider business mailing address

1312 E VAQUERO CT
CHULA VISTA CA
91910-8134
US

V. Phone/Fax

Practice location:
  • Phone: 971-222-6092
  • Fax:
Mailing address:
  • Phone: 971-222-6092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH5443
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: