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General NPI Number Information
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NPI Number | 1720424963
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Entity Type | Individual
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Provider Name | LISA MYRUM DMD
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Gender | Female
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Dates
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Enumeration Date | 05/15/2013
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Last Update Date | 07/08/2019
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Provider Practice Location Address
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Address Line | 2459 ARAMINGO AVE
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City | PHILADELPHIA
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State | PA
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Zip | 19125-3731
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Country | US
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Telephone | 215-427-2800
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Fax |
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Provider Business Mailing Address
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Address Line | 350 N CLARK ST FL 6 DENTAL DREAMS LLC C/O JULIETTE BOYCE
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City | CHICAGO
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State | IL
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Zip | 60654-4712
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DS039524
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | DS039524
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License Number State | PA
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