Provider Demographics
NPI:1225262488
Name:PERSICO, ELIZABETH SOPHIE (DMD)
Entity Type:Individual
Prefix:MISS
First Name:ELIZABETH
Middle Name:SOPHIE
Last Name:PERSICO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:SOPHIE
Other - Last Name:JAMIOLKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:78 LAIGHT ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-2016
Mailing Address - Country:US
Mailing Address - Phone:212-966-6680
Mailing Address - Fax:
Practice Address - Street 1:15 E 91ST ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-0648
Practice Address - Country:US
Practice Address - Phone:212-966-6680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-03
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055145122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist