# MICHAEL LYSONSKI DDS LLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Other names:** Edgewood Dental
- **Organization subpart:** No

## Provider details

- **NPI number:** 1427513902
- **Authorized official:** DR. MICHAEL LYSONSKI DDS (DR.)
- **Authorized official phone:** (262) 391-6179

## Contact information

- **Practice address:** 1917 OLD US 66, SUITE B-C-D1, EDGEWOOD, NM 87015-6799
- **Practice address phone:** (262) 391-6179
- **Mailing address:** 1520 LA TUNA PL SE, ALBUQUERQUE, NM 87123-4412
- **Mailing address phone:** (262) 391-6179

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | — | NULL | Yes |
| 1223G0001X | General Practice Dentistry | — | — | Yes |

## Other

- **Enumeration date:** 02/08/2019
- **Last updated:** 03/07/2023

## 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 |