Provider Demographics
NPI:1336712207
Name:LISYANSKY, MARIA (DMD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:LISYANSKY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10101 BREN RD E UNIT 247
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-0038
Mailing Address - Country:US
Mailing Address - Phone:412-628-5965
Mailing Address - Fax:
Practice Address - Street 1:16138 PILOT KNOB RD
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-4105
Practice Address - Country:US
Practice Address - Phone:952-679-7779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX375721223G0001X
MND148441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice