Healthcare Provider Details

I. General information

NPI: 1245398924
Provider Name (Legal Business Name): ERIC P. LIEDTKE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6855 S 27TH ST
FRANKLIN WI
53132-8045
US

IV. Provider business mailing address

11711 W BURLEIGH ST
WAUWATOSA WI
53222-3196
US

V. Phone/Fax

Practice location:
  • Phone: 414-435-0787
  • Fax:
Mailing address:
  • Phone: 414-771-2345
  • Fax: 630-904-3963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1001971
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021001663
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: