Healthcare Provider Details

I. General information

NPI: 1306918487
Provider Name (Legal Business Name): TRACEY LEE LYSANDER DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15835 POMERADO RD STE 403
POWAY CA
92064-2043
US

IV. Provider business mailing address

15835 POMERADO RD STE 403
POWAY CA
92064-2043
US

V. Phone/Fax

Practice location:
  • Phone: 858-451-8321
  • Fax: 858-451-8302
Mailing address:
  • Phone: 858-451-8321
  • Fax: 858-451-8302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number32580
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: