Provider Demographics
NPI:1457354417
Name:ANTONOFF, LISA R (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:R
Last Name:ANTONOFF
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 1:17 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-4324
Mailing Address - Country:US
Mailing Address - Phone:212-213-1897
Mailing Address - Fax:212-213-8497
Practice Address - Street 1:17 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4324
Practice Address - Country:US
Practice Address - Phone:212-213-1897
Practice Address - Fax:212-213-8497
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0407441223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics