Healthcare Provider Details

I. General information

NPI: 1215142765
Provider Name (Legal Business Name): DAVID B. LISTER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 SOUTH HIGHWAY 71
WEWAHITCHKA FL
32465
US

IV. Provider business mailing address

PO BOX 68
WEWAHITCHKA FL
32465-0068
US

V. Phone/Fax

Practice location:
  • Phone: 850-639-4565
  • Fax: 850-639-6565
Mailing address:
  • Phone: 850-639-4565
  • Fax: 850-639-6565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number15437
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: