MEDICARE: DR. JUSTIN WILLIAM LISKA D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	31680	TX

General Provider Information

NPI Number	:	1912290453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUSTIN WILLIAM LISKA D.D.S.

Provider Business Mailing Address
First Line	:	2249 N LOOP 336 W
Second Line	:	SUITE A
City	:	CONROE
State	:	TX
Zip	:	77304-3639
Country	:	US
Telephone Number	:	713-542-7001
Fax Number	:

Provider Business Practice Location Address
First Line	:	2249 N LOOP 336 W
Second Line	:	SUITE A
City	:	CONROE
State	:	TX
Zip	:	77304-3639
Country	:	US
Telephone Number	:	936-441-8180
Fax Number	:	936-441-1905

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2011
Last Update Date	:	08/30/2016

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