Provider Demographics
NPI:1326031352
Name:LIEM, HERMAN G T (D D S)
Entity Type:Individual
Prefix:DR
First Name:HERMAN
Middle Name:G T
Last Name:LIEM
Suffix:
Gender:M
Credentials:D D S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1600
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-1600
Mailing Address - Country:US
Mailing Address - Phone:541-247-8000
Mailing Address - Fax:541-247-8888
Practice Address - Street 1:29814 N ELLENSBURG AVE
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444-1600
Practice Address - Country:US
Practice Address - Phone:541-247-8000
Practice Address - Fax:541-247-8000
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD69421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice