Provider Demographics
NPI:1902026412
Name:PORAPAIBOON, LISA KAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:KAY
Last Name:PORAPAIBOON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3012 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-2808
Mailing Address - Country:US
Mailing Address - Phone:303-587-6498
Mailing Address - Fax:773-384-3500
Practice Address - Street 1:3012 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2808
Practice Address - Country:US
Practice Address - Phone:303-587-6498
Practice Address - Fax:773-384-3500
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8761122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO98608771Medicaid