Provider Demographics
NPI:1669904694
Name:MALKIEWICH, LISA NICOLE (DDS)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:NICOLE
Last Name:MALKIEWICH
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 1:208 LIVINGSTON ST APT 2
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-1510
Mailing Address - Country:US
Mailing Address - Phone:732-881-0102
Mailing Address - Fax:
Practice Address - Street 1:821 TENNENT RD
Practice Address - Street 2:
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-8250
Practice Address - Country:US
Practice Address - Phone:732-536-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI026814001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice