MEDICARE: LISANNE LYLE DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DS045398	PA

General Provider Information

NPI Number	:	1710862107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISANNE LYLE DMD

Provider Business Mailing Address
First Line	:	1974 DALLAS ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19138-2127
Country	:	US
Telephone Number	:	908-210-4123
Fax Number	:

Provider Business Practice Location Address
First Line	:	1732 S BROAD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-2330
Country	:	US
Telephone Number	:	215-336-8391
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2025
Last Update Date	:	08/06/2025

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