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Organization
MICHAEL LYSONSKI DDS LLC
Active
Organization
MICHAEL LYSONSKI DDS LLC
Active
Other names
Edgewood Dental
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MICHAEL LYSONSKI DDS (DR.)
(262) 391-6179
Entity
Organization
Contact information
Practice address
1917 OLD US 66, SUITE B-C-D1, EDGEWOOD, NM 87015-6799
(262) 391-6179
Mailing address
1520 LA TUNA PL SE, ALBUQUERQUE, NM 87123-4412
(262) 391-6179
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
NULL
1223G0001X
General Practice Dentistry
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
03-426588-00-0
NMCRS
NM
05
—
17933030
—
NM
01
—
CS00220539
NM CONTROLLED SUBSTANCE
NM
01
—
DD4113
NM DENTAL LICENSE
NM
Enumeration date
02/08/2019
Last updated
03/07/2023
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