Healthcare Provider Details

I. General information

NPI: 1982979506
Provider Name (Legal Business Name): LISA HENRIKA VAN EYNDHOVEN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2012
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 CHESAPEAKE BLVD STE E
ELKTON MD
21921-6391
US

IV. Provider business mailing address

103 CHESAPEAKE BLVD STE E
ELKTON MD
21921-6391
US

V. Phone/Fax

Practice location:
  • Phone: 410-648-2211
  • Fax:
Mailing address:
  • Phone: 410-648-2211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number15660
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number22DI02558300
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number8683136
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: