Healthcare Provider Details

I. General information

NPI: 1548946759
Provider Name (Legal Business Name): LISA MARINI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 GLEN COVE AVE
GLEN HEAD NY
11545-1651
US

IV. Provider business mailing address

345 E 24TH ST
NEW YORK NY
10010-4020
US

V. Phone/Fax

Practice location:
  • Phone: 516-200-5800
  • Fax:
Mailing address:
  • Phone: 212-998-9800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number064918
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: