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
—
—
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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