Healthcare Provider Details

I. General information

NPI: 1780110684
Provider Name (Legal Business Name): LISBON TECH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 MEDICAL PKWY STE 101
DALLAS TX
75234-7852
US

IV. Provider business mailing address

9 MEDICAL PKWY STE 101
DALLAS TX
75234-7852
US

V. Phone/Fax

Practice location:
  • Phone: 972-919-4747
  • Fax: 972-919-4749
Mailing address:
  • Phone: 888-544-3339
  • Fax: 214-853-5728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: DUSTIN RAY
Title or Position: OWNER
Credential:
Phone: 888-544-3339