=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912094830
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA E FLETCHER D.M.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2006
-----------------------------------------------------
Last Update Date | 11/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1047 S. HWY 92 SUITE A
-----------------------------------------------------
City | DANDRIDGE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-397-2956
-----------------------------------------------------
Fax | 865-299-7988
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 614 BERRY RD
-----------------------------------------------------
City | BULLS GAP
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37711-3821
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-218-6789
-----------------------------------------------------
Fax | 850-609-6796
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 11049
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 11709
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------