Basic Information
| Provider Information | |||||||||
| NPI: | 1609267244 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 718 SMYTH RD. | ||||||||
| Address2: | VA MEDICAL CENTER DENTAL SERVICE 160 | ||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036244366 | ||||||||
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| Practice Location | |||||||||
| Address1: | 718 SMYTH RD. | ||||||||
| Address2: | VA MEDICAL CENTER DENTAL SERVICE 160 | ||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036244366 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2015 | ||||||||
| LastUpdateDate: | 02/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 01619 | NH | Y | Dental Providers | Dental Hygienist |
No ID Information.