Healthcare Provider Details

I. General information

NPI: 1124048962
Provider Name (Legal Business Name): RICHARD ELDRED LUSBY D.D.S.
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

308 DORLA COURT SUITE 202
ZEPHYR COVE NV
89449
US

IV. Provider business mailing address

PO BOX 10230 308 DORLA COURT SUITE 202
ZEPHYR COVE NV
89448-2230
US

V. Phone/Fax

Practice location:
  • Phone: 775-588-8484
  • Fax: 775-588-6143
Mailing address:
  • Phone: 775-588-8484
  • Fax: 775-588-6143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number917
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: