Healthcare Provider Details

I. General information

NPI: 1326884677
Provider Name (Legal Business Name): LISA ANDERSON DENTAL HYGIENIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2024
Last Update Date: 07/06/2024
Certification Date: 07/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 ECLIPSE CTR
BELOIT WI
53511-3550
US

IV. Provider business mailing address

12030 E B C TOWNLINE RD
CLINTON WI
53525-8708
US

V. Phone/Fax

Practice location:
  • Phone: 608-361-0311
  • Fax:
Mailing address:
  • Phone: 608-290-9631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number7001489
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: