Healthcare Provider Details

I. General information

NPI: 1457354417
Provider Name (Legal Business Name): LISA R ANTONOFF D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 PARK AVE
NEW YORK NY
10016-4324
US

IV. Provider business mailing address

17 PARK AVE
NEW YORK NY
10016-4324
US

V. Phone/Fax

Practice location:
  • Phone: 212-213-1897
  • Fax: 212-213-8497
Mailing address:
  • Phone: 212-213-1897
  • Fax: 212-213-8497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number040744
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: