Provider Demographics
NPI:1285852335
Name:DE LISI, PETER JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOSEPH
Last Name:DE LISI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 OLD MAMARONECK RD
Mailing Address - Street 2:SUITE 1H
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-2010
Mailing Address - Country:US
Mailing Address - Phone:914-686-5040
Mailing Address - Fax:914-686-6181
Practice Address - Street 1:12 OLD MAMARONECK RD
Practice Address - Street 2:SUITE 1H
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-2010
Practice Address - Country:US
Practice Address - Phone:914-686-5040
Practice Address - Fax:914-686-6181
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0416801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice