Provider Demographics
NPI:1235468232
Name:MCCOY, LISA DANIELLE
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:DANIELLE
Last Name:MCCOY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 HOYT ST APT 5B
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5765
Mailing Address - Country:US
Mailing Address - Phone:734-395-7546
Mailing Address - Fax:
Practice Address - Street 1:3043A MAIN STREET
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033
Practice Address - Country:US
Practice Address - Phone:860-657-9212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-22
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2-0101761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice