Provider Demographics
NPI:1902056591
Name:GEORGE, LISA A (BDS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:GEORGE
Suffix:
Gender:F
Credentials:BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 CLOCK TOWER PLZ
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-7800
Mailing Address - Country:US
Mailing Address - Phone:847-701-1454
Mailing Address - Fax:888-496-7603
Practice Address - Street 1:2050 E ALGONQUIN RD
Practice Address - Street 2:SUITE 610
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-4144
Practice Address - Country:US
Practice Address - Phone:847-701-1454
Practice Address - Fax:888-496-7603
Is Sole Proprietor?:No
Enumeration Date:2008-09-19
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029470122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1300237Medicaid