Provider Demographics
NPI:1104000843
Name:LYSSOVA, VALENTINA (DDS)
Entity Type:Individual
Prefix:DR
First Name:VALENTINA
Middle Name:
Last Name:LYSSOVA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 E 40TH ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-1723
Mailing Address - Country:US
Mailing Address - Phone:646-812-2449
Mailing Address - Fax:
Practice Address - Street 1:319 AVENUE C
Practice Address - Street 2:7B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10009-1618
Practice Address - Country:US
Practice Address - Phone:646-812-2449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0521301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02700714Medicaid