Provider Demographics
NPI:1245398924
Name:LIEDTKE, ERIC P (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:P
Last Name:LIEDTKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11711 W BURLEIGH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3196
Mailing Address - Country:US
Mailing Address - Phone:414-771-2345
Mailing Address - Fax:630-904-3963
Practice Address - Street 1:6855 S 27TH ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-8045
Practice Address - Country:US
Practice Address - Phone:414-435-0787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10019711223X0400X
IL0210016631223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics