MEDICARE: DR. MATTHEW ROSS LISENBY 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	7249	NV
2	1223G0001X	General Practice Dentistry	7249	NV

General Provider Information

NPI Number	:	1992367338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW ROSS LISENBY DMD

Provider Business Mailing Address
First Line	:	9241 EVERGREEN CANYON DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-6063
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1457 S CARSON ST STE 101
Second Line	:
City	:	CARSON CITY
State	:	NV
Zip	:	89701-5240
Country	:	US
Telephone Number	:	775-372-9898
Fax Number	:

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

Provider Enumeration Date	:	07/06/2019
Last Update Date	:	05/16/2022

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