Provider Demographics
NPI:1649228958
Name:KISBY, LANCE E (DMD)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:E
Last Name:KISBY
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 1:1005 DR D B TODD JR BLVD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37208
Mailing Address - Country:US
Mailing Address - Phone:615-920-5954
Mailing Address - Fax:
Practice Address - Street 1:1005 DR D B TODD JR BLVD
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37208
Practice Address - Country:US
Practice Address - Phone:615-920-5954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS101091223P0221X
PADS0371211223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
V12422Medicare UPIN
V12422Medicare UPIN
PA110951Medicare PIN