Provider Demographics
NPI:1104198811
Name:KAST, LISL I (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISL
Middle Name:I
Last Name:KAST
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 1:3579 MERRICK RD
Mailing Address - Street 2:
Mailing Address - City:SENFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783
Mailing Address - Country:US
Mailing Address - Phone:516-721-2063
Mailing Address - Fax:516-221-2018
Practice Address - Street 1:3579 MERRICK RD
Practice Address - Street 2:
Practice Address - City:SENFORD
Practice Address - State:NY
Practice Address - Zip Code:11783
Practice Address - Country:US
Practice Address - Phone:516-721-2063
Practice Address - Fax:516-221-2018
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20737122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist