1427513902 NPI number — MICHAEL LYSONSKI DDS LLC

Table of content: (NPI 1427513902)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427513902 NPI number — MICHAEL LYSONSKI DDS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL LYSONSKI DDS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427513902
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1520 LA TUNA PL SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87123-4412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-391-6179
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1917 OLD US 66
Provider Second Line Business Practice Location Address:
SUITE B-C-D1
Provider Business Practice Location Address City Name:
EDGEWOOD
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87015-6799
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-391-6179
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/08/2019

Additional Information

Authorized Official

Authorized Official Last Name:
LYSONSKI
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
DR.
Authorized Official Telephone Number:
262-391-6179

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 17933030 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: DD4113 . This is a "NM DENTAL LICENSE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 03-426588-00-0 . This is a "NMCRS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: CS00220539 . This is a "NM CONTROLLED SUBSTANCE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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