Provider Demographics
NPI:1871691600
Name:MANNION-BLACK, LISELOTTE ALICE (DDS)
Entity type:Individual
Prefix:MRS
First Name:LISELOTTE
Middle Name:ALICE
Last Name:MANNION-BLACK
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 1:8400 W GAGE BLVD
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-1075
Mailing Address - Country:US
Mailing Address - Phone:509-735-9548
Mailing Address - Fax:509-735-6876
Practice Address - Street 1:8400 W GAGE BLVD
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-1075
Practice Address - Country:US
Practice Address - Phone:509-735-9548
Practice Address - Fax:509-735-6876
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000073131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice