Provider Demographics
NPI:1518025899
Name:LISH, JEROME (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:
Last Name:LISH
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 1:7224 AVENUE T
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-6235
Mailing Address - Country:US
Mailing Address - Phone:718-763-1817
Mailing Address - Fax:718-251-6990
Practice Address - Street 1:7224 AVENUE T
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-6235
Practice Address - Country:US
Practice Address - Phone:718-763-1817
Practice Address - Fax:718-251-6990
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228461223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics