Basic Information
| Provider Information | |||||||||
| NPI: | 1952301582 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLSON-MARKS | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2556 S CLAYTON ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802106115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033771148 | ||||||||
| FaxNumber: | 3033882142 | ||||||||
| Practice Location | |||||||||
| Address1: | 4500 CHERRY CREEK SOUTH DR | ||||||||
| Address2: | # 840 | ||||||||
| City: | GLENDALE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802461518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033771148 | ||||||||
| FaxNumber: | 3033882142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 05/16/2012 | ||||||||
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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 | 1223P0221X | 7396 | CO | Y | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 71905774 | 05 | CO | MEDICAID | 55931375 | 05 | CO | MEDICAID |