Provider Demographics
NPI:1902916307
Name:MULKIN, LISA KAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:KAY
Last Name:MULKIN
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 1:404 WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-2143
Mailing Address - Country:US
Mailing Address - Phone:315-789-3067
Mailing Address - Fax:315-789-0056
Practice Address - Street 1:404 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-2143
Practice Address - Country:US
Practice Address - Phone:315-789-3067
Practice Address - Fax:315-789-0056
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050514-11223G0001X, 1223X2210X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice
No1223X2210XDental ProvidersDentistOrofacial Pain
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY050514OtherNEW YORK STATE LICENSE
NY70455LMOtherBC/BS PROVIDER NUMBER
NYBM8408901OtherDEA NUMBER