Provider Demographics
NPI:1598336117
Name:KISANOVA LIPKIN, DINA (DMD)
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:
Last Name:KISANOVA LIPKIN
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 1:7441 WAYNE AVE APT 2C
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33141-2539
Mailing Address - Country:US
Mailing Address - Phone:305-244-6015
Mailing Address - Fax:
Practice Address - Street 1:4267 W COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33319-3305
Practice Address - Country:US
Practice Address - Phone:954-677-3202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN26139122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist