Healthcare Provider Details

I. General information

NPI: 1639320633
Provider Name (Legal Business Name): LISA B COHEN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 07/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 ROUTE 59 SUITE #210
SUFFERN NY
10901-5204
US

IV. Provider business mailing address

222 ROUTE 59 SUITE #210
SUFFERN NY
10901-5204
US

V. Phone/Fax

Practice location:
  • Phone: 845-369-1540
  • Fax:
Mailing address:
  • Phone: 845-369-1540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number052670
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01620680
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: