=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568817088
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | E. LISA REID DMD, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2016
-----------------------------------------------------
Last Update Date | 05/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 130 E 18TH ST SUITE 1M
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003-2416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-675-6606
-----------------------------------------------------
Fax | 212-614-3223
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 63 FORT GREENE PL APT 8
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11217-1241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-675-6606
-----------------------------------------------------
Fax | 212-614-3223
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ELEANOR REID
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 347-675-6606
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 054312
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------