Provider Demographics
NPI:1083825004
Name:LYSDALE, JEFFREY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:LYSDALE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 KIRK DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86404
Mailing Address - Country:US
Mailing Address - Phone:949-351-7343
Mailing Address - Fax:
Practice Address - Street 1:2311 S CASINO DR STE D
Practice Address - Street 2:
Practice Address - City:LAUGHLIN
Practice Address - State:NV
Practice Address - Zip Code:89029-1534
Practice Address - Country:US
Practice Address - Phone:702-298-4545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4186122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist