Provider Demographics
NPI:1811321086
Name:LYSENKO, JENNIFER VAUGHN (DDS)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:VAUGHN
Last Name:LYSENKO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1064 GRAVES MILL RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1604 GRAVES MILL RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-5174
Practice Address - Country:US
Practice Address - Phone:434-385-7307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-24
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014144141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice