Provider Demographics
NPI:1902653447
Name:PETOFF MAIROWITZ, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PETOFF MAIROWITZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:AVON BY THE SEA
Mailing Address - State:NJ
Mailing Address - Zip Code:07717-1157
Mailing Address - Country:US
Mailing Address - Phone:732-775-1492
Mailing Address - Fax:732-775-1498
Practice Address - Street 1:514 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:AVON BY THE SEA
Practice Address - State:NJ
Practice Address - Zip Code:07717-1157
Practice Address - Country:US
Practice Address - Phone:732-775-1492
Practice Address - Fax:732-775-1498
Is Sole Proprietor?:No
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DP00650600126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant