MEDICARE: STEPHANIE LIEM DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	1223G0001X	General Practice Dentistry	40447	TX

General Provider Information

NPI Number	:	1043915192
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE LIEM DDS

Provider Business Mailing Address
First Line	:	1711 NELSON DR
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75038-5963
Country	:	US
Telephone Number	:	469-579-7891
Fax Number	:

Provider Business Practice Location Address
First Line	:	12420 TIMBERLAND BLVD STE 416
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5230
Country	:	US
Telephone Number	:	817-799-5948
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2023
Last Update Date	:	06/22/2024

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Directions to “ STEPHANIE LIEM DDS” Practice Location

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