Provider Demographics
NPI:1437319324
Name:LISSY, JEFFREY STEVEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:STEVEN
Last Name:LISSY
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 1:10608 N TRADEMARK PKWY
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730
Mailing Address - Country:US
Mailing Address - Phone:909-987-7815
Mailing Address - Fax:775-323-2527
Practice Address - Street 1:10608 N TRADEMARK PKWY
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:909-987-7815
Practice Address - Fax:775-323-2527
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2494122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist