Healthcare Provider Details

I. General information

NPI: 1215354600
Provider Name (Legal Business Name): MICHAEL LYSONSKI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2014
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 CANYONLANDS PL SE
ALBUQUERQUE NM
87123-5734
US

IV. Provider business mailing address

11800 CANYONLANDS PL SE
ALBUQUERQUE NM
87123-5734
US

V. Phone/Fax

Practice location:
  • Phone: 262-391-6179
  • Fax:
Mailing address:
  • Phone: 262-391-6179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD4113
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number7245-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: