=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982979506
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA HENRIKA VAN EYNDHOVEN DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2012
-----------------------------------------------------
Last Update Date | 11/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 CHESAPEAKE BLVD STE E
-----------------------------------------------------
City | ELKTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21921-6391
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-648-2211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 CHESAPEAKE BLVD STE E
-----------------------------------------------------
City | ELKTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21921-6391
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-648-2211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 15660
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 22DI02558300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 8683136
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------