Provider Demographics
NPI:1265686976
Name:LISS, MICHAEL STEVEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:STEVEN
Last Name:LISS
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 1:3567 GRAND AVE STE E
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-4606
Mailing Address - Country:US
Mailing Address - Phone:847-662-9234
Mailing Address - Fax:
Practice Address - Street 1:3567 GRAND AVE STE E
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-4606
Practice Address - Country:US
Practice Address - Phone:847-662-9234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190205951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice