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General NPI Number Information
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NPI Number | 1134790454
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Entity Type | Organization
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Legal Business Name | MATTHEW LIESEN, DMD PLLC
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Dates
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Enumeration Date | 07/07/2021
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Last Update Date | 07/07/2021
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Provider Practice Location Address
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Address Line | 3 COLLINSPORT DR
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City | COLLINSVILLE
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State | IL
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Zip | 62234-6104
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Country | US
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Telephone | 618-344-6459
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Fax |
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Provider Business Mailing Address
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Address Line | 3 COLLINSPORT DR
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City | COLLINSVILLE
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State | IL
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Zip | 62234-6104
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Country | US
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Telephone | 618-344-6459
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Fax |
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Authorized Official
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Title or Position | OWNER/GENERAL DENTIST
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Name | MATTHEW J LIESEN
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Credential | DMD
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Telephone | 217-248-4561
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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