Basic Information
| Provider Information | |||||||||
| NPI: | 1639243975 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VALENTINE | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16 WINDY MEADOW CT | ||||||||
| Address2: | |||||||||
| City: | RANDALLSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211334346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108520928 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6700 ALEXANDER BELL DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210462122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889646681 | ||||||||
| FaxNumber: | 8886620859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 09/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 12365 | MD | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 006960357 | 01 | ADA | OTHER | 010878200 | 05 | MD | MEDICAID | 12189777 | 01 | CAQH | OTHER |