Healthcare Provider Details

I. General information

NPI: 1902068372
Provider Name (Legal Business Name): NATASHA ALEXIS LISIN-QUEEN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2008
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

592 MEDICAL PARK DR STE B
GAINESVILLE GA
30501-2055
US

IV. Provider business mailing address

230 CHICKERING LAKE DR
ROSWELL GA
30075-3278
US

V. Phone/Fax

Practice location:
  • Phone: 678-498-1441
  • Fax:
Mailing address:
  • Phone: 314-498-9006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN014359
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN31461
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: