Provider Demographics
NPI:1407912538
Name:LIZZACK, JASON HOWARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:HOWARD
Last Name:LIZZACK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17-10 RIVER RD STE 4B
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-1250
Mailing Address - Country:US
Mailing Address - Phone:201-797-7774
Mailing Address - Fax:201-797-0740
Practice Address - Street 1:17-10 RIVER RD STE 4B
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-1250
Practice Address - Country:US
Practice Address - Phone:201-797-7774
Practice Address - Fax:201-797-0740
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0510141223G0001X
NJ22DI021664001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02556921Medicaid