MEDICARE: MRS. LISA BLAIR RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	5965	WA

General Provider Information

NPI Number	:	1174828495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA BLAIR RDH

Provider Business Mailing Address
First Line	:	343 WELLSIAN WAY
Second Line	:	SUITE 103
City	:	RICHLAND
State	:	WA
Zip	:	99352-4107
Country	:	US
Telephone Number	:	509-967-5344
Fax Number	:	509-943-9020

Provider Business Practice Location Address
First Line	:	343 WELLSIAN WAY
Second Line	:	SUITE 103
City	:	RICHLAND
State	:	WA
Zip	:	99352-4107
Country	:	US
Telephone Number	:	509-967-5344
Fax Number	:	509-943-9020

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2011
Last Update Date	:	01/18/2011

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