Provider Demographics
NPI:1861003873
Name:LILLY, LIDIA (DDS, RN)
Entity Type:Individual
Prefix:DR
First Name:LIDIA
Middle Name:
Last Name:LILLY
Suffix:
Gender:F
Credentials:DDS, RN
Other - Prefix:DR
Other - First Name:LIDIA
Other - Middle Name:
Other - Last Name:LYSKANOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:3050 CHEEVER ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37064-1792
Mailing Address - Country:US
Mailing Address - Phone:615-972-3204
Mailing Address - Fax:
Practice Address - Street 1:3050 CHEEVER ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37064-1792
Practice Address - Country:US
Practice Address - Phone:615-972-3204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS0000011310122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist