MEDICARE: DR. LISA TONI DAVIS KULP D.M.D.

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	1223G0001X	General Practice Dentistry	2904	AZ

General Provider Information

NPI Number	:	1528064169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA TONI DAVIS KULP D.M.D.

Provider Business Mailing Address
First Line	:	3028 E NORTHRIDGE ST
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85213-1631
Country	:	US
Telephone Number	:	480-924-3062
Fax Number	:

Provider Business Practice Location Address
First Line	:	4517 N 32ND ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85018-3339
Country	:	US
Telephone Number	:	480-924-3062
Fax Number	:

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

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	07/08/2007

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