Healthcare Provider Details

I. General information

NPI: 1609052877
Provider Name (Legal Business Name): LISKA M ANDU DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 01/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5026 WINDING HILLS LN
WOODSTOCK GA
30189-2582
US

IV. Provider business mailing address

3525 BUSBEE DR NW SUITE 200
KENNESAW GA
30144-5511
US

V. Phone/Fax

Practice location:
  • Phone: 770-591-3947
  • Fax:
Mailing address:
  • Phone: 678-836-2115
  • Fax: 770-441-0299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number011227
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: