MEDICARE: ALAN LIESINGER DMD PC

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	1223E0200X	Endodontics	667595	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	168369	OTHER		WELFARE PROVIDER #

General Provider Information

NPI Number	:	1568711257
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALAN LIESINGER DMD PC

Provider Business Mailing Address
First Line	:	375 PARK AVE., SUITE 7
Second Line	:
City	:	COOS BAY
State	:	OR
Zip	:	97420-2242
Country	:	US
Telephone Number	:	541-267-2329
Fax Number	:	541-267-4026

Provider Business Practice Location Address
First Line	:	375 PARK AVE., SUITE 7
Second Line	:
City	:	COOS BAY
State	:	OR
Zip	:	97420-2242
Country	:	US
Telephone Number	:	541-267-2329
Fax Number	:	541-267-4026

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. SUSAN LESLIE LIESINGER
Credential	:
Telephone Number	:	541-269-2329

Provider Enumeration Date	:	09/10/2012
Last Update Date	:	09/10/2012

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