Provider Demographics
NPI:1770628877
Name:LIS, STANLEY J (DDS)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:J
Last Name:LIS
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 1:74 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-1537
Mailing Address - Country:US
Mailing Address - Phone:518-439-3299
Mailing Address - Fax:518-439-3589
Practice Address - Street 1:74 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-1537
Practice Address - Country:US
Practice Address - Phone:518-439-3299
Practice Address - Fax:518-439-3589
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035858-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice