Provider Demographics
NPI:1992367338
Name:LISENBY, MATTHEW ROSS (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ROSS
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 1:9241 EVERGREEN CANYON DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89134-6063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1457 S CARSON ST STE 101
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89701-5240
Practice Address - Country:US
Practice Address - Phone:775-372-9898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-06
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7249122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentistGroup - Single Specialty