Provider Demographics
NPI:1528650710
Name:JEDACEK, LISA ANN (DMD, MPH)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:JEDACEK
Suffix:
Gender:F
Credentials:DMD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 MAYFLOWER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-4103
Mailing Address - Country:US
Mailing Address - Phone:440-665-3973
Mailing Address - Fax:
Practice Address - Street 1:1400 PELHAM PKWY S
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1197
Practice Address - Country:US
Practice Address - Phone:718-918-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI03015700122300000X
VA0401418721122300000X, 1223D0004X
MADN100003151223D0004X, 122300000X
MI29016020931223D0004X, 122300000X
OH30.027607122300000X, 1223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDental Anesthesiology
No122300000XDental ProvidersDentist