Healthcare Provider Details

I. General information

NPI: 1093767741
Provider Name (Legal Business Name): LIESL KIRSTEN BREDESON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 FOREST LN STE D-1200
DALLAS TX
75230-2571
US

IV. Provider business mailing address

7777 FOREST LN STE D-1200
DALLAS TX
75230-2571
US

V. Phone/Fax

Practice location:
  • Phone: 214-365-1150
  • Fax: 214-363-2477
Mailing address:
  • Phone: 214-365-1150
  • Fax: 214-363-2477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberK3012
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberK3012
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: