Provider Demographics
NPI:1093892390
Name:ANTONELLI, LISA ANNE (DMD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANNE
Last Name:ANTONELLI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 PLANTATION STREET
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604
Mailing Address - Country:US
Mailing Address - Phone:508-753-1911
Mailing Address - Fax:508-753-1837
Practice Address - Street 1:330 PLANTATION STREET
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604
Practice Address - Country:US
Practice Address - Phone:508-753-1911
Practice Address - Fax:508-753-1837
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA162041223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics