Healthcare Provider Details

I. General information

NPI: 1265054332
Provider Name (Legal Business Name): MARI LIESTMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2020
Last Update Date: 09/01/2021
Certification Date: 09/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 SANDBERG RD
MONTICELLO MN
55362-8906
US

IV. Provider business mailing address

3120 NORTHDALE BLVD NW UNIT 240
COON RAPIDS MN
55433-2996
US

V. Phone/Fax

Practice location:
  • Phone: 763-295-5400
  • Fax:
Mailing address:
  • Phone: 320-217-9940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD14650
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: