Provider Demographics
NPI:1427668029
Name:LISANN, RYAN
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:LISANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 RIVER ST APT 2B
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3818
Mailing Address - Country:US
Mailing Address - Phone:631-896-3506
Mailing Address - Fax:
Practice Address - Street 1:474 BROADWAY APT 110
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02145-2630
Practice Address - Country:US
Practice Address - Phone:617-623-2223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1858741122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty