MEDICARE: LISA MARKEL 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	00002226	MO

General Provider Information

NPI Number	:	1538765276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MARKEL RDH

Provider Business Mailing Address
First Line	:	5545 OSAGE BEACH PKWY UNIT 362
Second Line	:
City	:	OSAGE BEACH
State	:	MO
Zip	:	65065-0077
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4800 EAGLEVIEW DR # 135B
Second Line	:
City	:	OSAGE BEACH
State	:	MO
Zip	:	65065-2757
Country	:	US
Telephone Number	:	636-541-9224
Fax Number	:

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

Provider Enumeration Date	:	12/08/2020
Last Update Date	:	12/08/2020

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