Provider Demographics
NPI:1629248414
Name:LISENBY, KYLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:LISENBY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 N KEENE ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6623
Mailing Address - Country:US
Mailing Address - Phone:573-571-2222
Mailing Address - Fax:573-817-2888
Practice Address - Street 1:303 N KEENE ST
Practice Address - Street 2:SUITE 208
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6623
Practice Address - Country:US
Practice Address - Phone:573-571-2222
Practice Address - Fax:573-817-2888
Is Sole Proprietor?:No
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008006645 M122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist