Provider Demographics
NPI:1356489116
Name:LIZA DENTAL MANAGEMENT INC.
Entity Type:Organization
Organization Name:LIZA DENTAL MANAGEMENT INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:YERMOLENKO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:908-352-2207
Mailing Address - Street 1:1219 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:07205-2055
Mailing Address - Country:US
Mailing Address - Phone:908-352-2207
Mailing Address - Fax:908-352-2208
Practice Address - Street 1:1219 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:HILLSIDE
Practice Address - State:NJ
Practice Address - Zip Code:07205-2055
Practice Address - Country:US
Practice Address - Phone:908-352-2207
Practice Address - Fax:908-352-2208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ19838261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental