Healthcare Provider Details

I. General information

NPI: 1083825004
Provider Name (Legal Business Name): JEFFREY LYSDALE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 S CASINO DR STE D
LAUGHLIN NV
89029-1534
US

IV. Provider business mailing address

1830 KIRK DRIVE
LAKE HAVASU CITY AZ
86404
US

V. Phone/Fax

Practice location:
  • Phone: 702-298-4545
  • Fax:
Mailing address:
  • Phone: 949-351-7343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4186
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: