Provider Demographics
NPI:1396039087
Name:INDELICATO, LISA MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:INDELICATO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-1428
Mailing Address - Country:US
Mailing Address - Phone:718-757-1284
Mailing Address - Fax:
Practice Address - Street 1:300 2ND AVE
Practice Address - Street 2:
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6303
Practice Address - Country:US
Practice Address - Phone:732-923-6585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-31
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02471800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist