Provider Demographics
NPI:1245329507
Name:LOZOVER, LARISA (DDS)
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:LOZOVER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 AVENUE U
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-3822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:718-265-0700
Practice Address - Street 1:271 AVENUE U
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-3822
Practice Address - Country:US
Practice Address - Phone:718-265-5700
Practice Address - Fax:718-265-0700
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2010-07-15
Deactivation Date:2008-04-08
Deactivation Code:
Reactivation Date:2010-07-13
Provider Licenses
StateLicense IDTaxonomies
NY049867122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02265832Medicaid