MEDICARE: RONALD LISS 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	19022882	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	31552	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1336220821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RONALD LISS DDS

Provider Business Mailing Address
First Line	:	1000 GRAND CANYON PARKWAY
Second Line	:	SUITE 106
City	:	HOFFMAN ESTATES
State	:	IL
Zip	:	60169-1705
Country	:	US
Telephone Number	:	847-519-0600
Fax Number	:	847-519-0693

Provider Business Practice Location Address
First Line	:	1000 GRAND CANYON PARKWAY
Second Line	:	SUITE 106
City	:	HOFFMAN ESTATES
State	:	IL
Zip	:	60169-1705
Country	:	US
Telephone Number	:	847-519-0600
Fax Number	:	847-519-0693

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

Provider Enumeration Date	:	10/18/2006
Last Update Date	:	05/14/2025

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