Provider Demographics
NPI:1073615449
Name:ECKENSTEIN, LISA DIANE (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:DIANE
Last Name:ECKENSTEIN
Suffix:
Gender:F
Credentials:DDS, MS
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Mailing Address - Street 1:16624 SOUTH 107TH COURT
Mailing Address - Street 2:UNIT B
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-8898
Mailing Address - Country:US
Mailing Address - Phone:708-460-7556
Mailing Address - Fax:
Practice Address - Street 1:16624 SOUTH 107TH COURT
Practice Address - Street 2:UNIT B
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-8898
Practice Address - Country:US
Practice Address - Phone:708-460-7556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223X0400X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics