Provider Demographics
NPI:1093005449
Name:LISOV, NATALIA (RDH)
Entity Type:Individual
Prefix:MRS
First Name:NATALIA
Middle Name:
Last Name:LISOV
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-4723
Mailing Address - Country:US
Mailing Address - Phone:315-793-7600
Mailing Address - Fax:
Practice Address - Street 1:1651 ONEIDA ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-4723
Practice Address - Country:US
Practice Address - Phone:315-793-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026297124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist