Provider Demographics
NPI:1942470406
Name:LIS SMILE DENTAL OFFICE PC
Entity type:Organization
Organization Name:LIS SMILE DENTAL OFFICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ZEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-238-4545
Mailing Address - Street 1:6924 13TH AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228-1624
Mailing Address - Country:US
Mailing Address - Phone:718-238-4545
Mailing Address - Fax:718-238-9084
Practice Address - Street 1:6924 13TH AVE
Practice Address - Street 2:SUI1FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11228-1624
Practice Address - Country:US
Practice Address - Phone:718-238-4545
Practice Address - Fax:718-238-9084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047770-1261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01892502Medicaid