Provider Demographics
NPI:1679770523
Name:LISTER, ANTHONY R (DDS)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:R
Last Name:LISTER
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:PO BOX 66
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:NY
Mailing Address - Zip Code:13420-0066
Mailing Address - Country:US
Mailing Address - Phone:153-369-6634
Mailing Address - Fax:
Practice Address - Street 1:114 S SHORE RD
Practice Address - Street 2:
Practice Address - City:OLD FORGE
Practice Address - State:NY
Practice Address - Zip Code:13420-7786
Practice Address - Country:US
Practice Address - Phone:315-369-6634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0528861223X0400X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics