Provider Demographics
NPI:1093056194
Name:LYSENKO, TATYANA
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:LYSENKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 ROUTE 38
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-9721
Mailing Address - Country:US
Mailing Address - Phone:856-722-0333
Mailing Address - Fax:856-437-6101
Practice Address - Street 1:3201 ROUTE 38
Practice Address - Street 2:SUITE 102
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-9721
Practice Address - Country:US
Practice Address - Phone:856-722-0333
Practice Address - Fax:856-437-6101
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-14
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01901700122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist