Healthcare Provider Details

I. General information

NPI: 1760015820
Provider Name (Legal Business Name): LISA ANN SOLTANI RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2020
Last Update Date: 02/18/2020
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1664 WEEKSVILLE RD BLDG 128
ELIZABETH CITY NC
27909-6701
US

IV. Provider business mailing address

108 WILLIAM DR
ELIZABETH CITY NC
27909-9457
US

V. Phone/Fax

Practice location:
  • Phone: 252-335-6460
  • Fax: 252-335-6255
Mailing address:
  • Phone: 775-287-1717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number12446
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: