Provider Demographics
NPI:1427513902
Name:MICHAEL LYSONSKI DDS LLC
Entity type:Organization
Organization Name:MICHAEL LYSONSKI DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LYSONSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-391-6179
Mailing Address - Street 1:1520 LA TUNA PL SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-4412
Mailing Address - Country:US
Mailing Address - Phone:262-391-6179
Mailing Address - Fax:
Practice Address - Street 1:1917 OLD US 66
Practice Address - Street 2:SUITE B-C-D1
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015-6799
Practice Address - Country:US
Practice Address - Phone:262-391-6179
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM17933030Medicaid
NMDD4113OtherNM DENTAL LICENSE
NM03-426588-00-0OtherNMCRS
NMCS00220539OtherNM CONTROLLED SUBSTANCE
NMFL4589101OtherDEA LICENSE