Provider Demographics
NPI:1447730304
Name:ROENING, LISA J
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:J
Last Name:ROENING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2626 REAGAN ST APT 443
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-2373
Mailing Address - Country:US
Mailing Address - Phone:415-542-6097
Mailing Address - Fax:
Practice Address - Street 1:814 E IRVING BLVD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75060-3148
Practice Address - Country:US
Practice Address - Phone:972-259-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34522122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist