Provider Demographics
NPI:1962760454
Name:YELIZAR, PETER (DDS)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:YELIZAR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4422 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-2545
Mailing Address - Country:US
Mailing Address - Phone:718-960-6628
Mailing Address - Fax:
Practice Address - Street 1:400 S OYSTER BAY RD STE 105
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801
Practice Address - Country:US
Practice Address - Phone:516-336-4902
Practice Address - Fax:516-336-4805
Is Sole Proprietor?:No
Enumeration Date:2012-05-02
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0107951223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223G0001XDental ProvidersDentistGeneral Practice