Healthcare Provider Details

I. General information

NPI: 1194774422
Provider Name (Legal Business Name): LISA KAY ROSS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 N DOUGLAS AVE
ELLSWORTH KS
67439-3215
US

IV. Provider business mailing address

1185 COLUMBINE CIR
SALINA KS
67401-9084
US

V. Phone/Fax

Practice location:
  • Phone: 785-472-3803
  • Fax: 785-472-3620
Mailing address:
  • Phone: 785-820-0857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2364
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: