Provider Demographics
NPI:1457747198
Name:BRUCE J LISH DDS PLLC
Entity Type:Organization
Organization Name:BRUCE J LISH DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:LISH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-763-1817
Mailing Address - Street 1:7224 AVENUE T
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-6235
Mailing Address - Country:US
Mailing Address - Phone:718-763-1817
Mailing Address - Fax:917-591-4970
Practice Address - Street 1:7224 AVENUE T
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-6235
Practice Address - Country:US
Practice Address - Phone:718-763-1817
Practice Address - Fax:917-591-4970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045725261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental