Provider Demographics
NPI:1902068372
Name:LISIN-QUEEN, NATASHA ALEXIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:NATASHA
Middle Name:ALEXIS
Last Name:LISIN-QUEEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 CHICKERING LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-3278
Mailing Address - Country:US
Mailing Address - Phone:314-498-9006
Mailing Address - Fax:
Practice Address - Street 1:3950 COBB PKWY NW
Practice Address - Street 2:SUITE 402
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-9532
Practice Address - Country:US
Practice Address - Phone:770-966-9396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA22194122300000X
GADN014359122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist