Provider Demographics
NPI:1730418526
Name:LUSTBADER, AMY (DDS)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:LUSTBADER
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 1:155 E 55TH ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-4038
Mailing Address - Country:US
Mailing Address - Phone:212-759-5595
Mailing Address - Fax:
Practice Address - Street 1:155 E 55TH ST
Practice Address - Street 2:SUITE 301
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-4038
Practice Address - Country:US
Practice Address - Phone:212-759-5595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-08
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053917-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist