Healthcare Provider Details

I. General information

NPI: 1518028455
Provider Name (Legal Business Name): LISA AUSTIN DMD, MSD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 SE 3RD ST STE A1
BEND OR
97702-2162
US

IV. Provider business mailing address

1245 SE 3RD ST STE A1
BEND OR
97702-2162
US

V. Phone/Fax

Practice location:
  • Phone: 541-318-5688
  • Fax:
Mailing address:
  • Phone: 541-318-5688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number10079
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD8548
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: