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NPI Code Detail

MEDICARE: JORDAN LISSAUER ORTHODONTICS PC

MEDICARE: JORDAN LISSAUER ORTHODONTICS PC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223X0400XOrthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number : 1851945794
Entity Type Code : Organization
Provider Name (Legal Business Name) : JORDAN LISSAUER ORTHODONTICS PC
Provider Business Mailing Address
First Line : 3767 HYLAN BLVD
Second Line :
City : STATEN ISLAND
State : NY
Zip : 10308-3505
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 3767 HYLAN BLVD
Second Line :
City : STATEN ISLAND
State : NY
Zip : 10308-3505
Country : US
Telephone Number : 718-966-2720
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : JORDAN LISSAUER
Credential : DMD
Telephone Number : 561-324-4030
Provider Enumeration Date : 07/29/2019
Last Update Date : 07/29/2019

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