Healthcare Provider Details

I. General information

NPI: 1740637941
Provider Name (Legal Business Name): LISSA CISNEROS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 04/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 OPPORTUNITY BLVD S
CAMBRIDGE MN
55008-1238
US

IV. Provider business mailing address

135 OPPORTUNITY BLVD S
CAMBRIDGE MN
55008-1238
US

V. Phone/Fax

Practice location:
  • Phone: 763-689-1554
  • Fax:
Mailing address:
  • Phone: 763-689-1554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD13670
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: