Provider Demographics
NPI:1447842430
Name:KOGA, LISEANE (DDS)
Entity type:Individual
Prefix:
First Name:LISEANE
Middle Name:
Last Name:KOGA
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 1:2124 FORSYTHE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3611
Mailing Address - Country:US
Mailing Address - Phone:318-388-4209
Mailing Address - Fax:
Practice Address - Street 1:2124 FORSYTHE AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3611
Practice Address - Country:US
Practice Address - Phone:318-388-4209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-10
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX369281223X0400X
LALA72861223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX36928OtherTSBDE
LALA7286OtherLA