Provider Demographics
NPI:1518608918
Name:LYSS, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:LYSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 WESTCHESTER HALL
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8711
Mailing Address - Country:US
Mailing Address - Phone:631-444-2557
Mailing Address - Fax:631-444-6013
Practice Address - Street 1:58 RUTLEDGE ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11249-7814
Practice Address - Country:US
Practice Address - Phone:718-260-4620
Practice Address - Fax:718-260-4626
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY063929122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist