Healthcare Provider Details

I. General information

NPI: 1568711257
Provider Name (Legal Business Name): ALAN LIESINGER DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 PARK AVE., SUITE 7
COOS BAY OR
97420-2242
US

IV. Provider business mailing address

375 PARK AVE., SUITE 7
COOS BAY OR
97420-2242
US

V. Phone/Fax

Practice location:
  • Phone: 541-267-2329
  • Fax: 541-267-4026
Mailing address:
  • Phone: 541-267-2329
  • Fax: 541-267-4026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number667595
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier168369
Identifier TypeOTHER
Identifier State
Identifier IssuerWELFARE PROVIDER #

VIII. Authorized Official

Name: MRS. SUSAN LESLIE LIESINGER
Title or Position: OFFICE MANAGER
Credential:
Phone: 541-269-2329