Provider Demographics
NPI:1306918487
Name:LYSANDER, TRACEY LEE (DDS)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:LEE
Last Name:LYSANDER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15835 POMERADO RD STE 403
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2043
Mailing Address - Country:US
Mailing Address - Phone:858-451-8321
Mailing Address - Fax:858-451-8302
Practice Address - Street 1:15835 POMERADO RD STE 403
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2043
Practice Address - Country:US
Practice Address - Phone:858-451-8321
Practice Address - Fax:858-451-8302
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32580122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist