Healthcare Provider Details

I. General information

NPI: 1295439768
Provider Name (Legal Business Name): LIA DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 03/29/2023
Certification Date: 03/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 LYNNFIELD ST
PEABODY MA
01960-5201
US

IV. Provider business mailing address

61 DUDLEY ST
MEDFORD MA
02155-4007
US

V. Phone/Fax

Practice location:
  • Phone: 917-892-3625
  • Fax:
Mailing address:
  • Phone: 917-892-3625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. SHAHNAAZ NISTAR
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 917-892-3625