Provider Demographics
NPI:1669832523
Name:LIAN, LISA (DMD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LIAN
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 1:28 MOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07059-5608
Mailing Address - Country:US
Mailing Address - Phone:908-293-9763
Mailing Address - Fax:
Practice Address - Street 1:28 MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:NJ
Practice Address - Zip Code:07059-5608
Practice Address - Country:US
Practice Address - Phone:908-293-9763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0601101223P0221X
NJ22DI026973001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY060110OtherNEW YORK STATE DENTAL LICENSE
NJ22DI02697300OtherNEW JERSEY DENTAL LICENSE