Provider Demographics
NPI:1578206306
Name:KATACH, LISA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:KATACH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:JRADA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:450 AVENUE X FL 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-6010
Mailing Address - Country:US
Mailing Address - Phone:347-439-2306
Mailing Address - Fax:
Practice Address - Street 1:450 AVENUE X FL 1
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-6010
Practice Address - Country:US
Practice Address - Phone:347-439-2306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-19
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0633191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program