Healthcare Provider Details

I. General information

NPI: 1033139845
Provider Name (Legal Business Name): KENT A LYSGAARD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7180 CASCADE VALLEY CT SUITE 100
LAS VEGAS NV
89128-0481
US

IV. Provider business mailing address

7180 CASCADE VALLEY CT SUITE 100
LAS VEGAS NV
89128-0481
US

V. Phone/Fax

Practice location:
  • Phone: 702-360-9061
  • Fax:
Mailing address:
  • Phone: 702-360-9061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2289
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: