Provider Demographics
NPI:1568616886
Name:LISTON, LAWRENCE ELLIOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:ELLIOTT
Last Name:LISTON
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 1:2103 E WASHINGTON ST STE 2D
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4365
Mailing Address - Country:US
Mailing Address - Phone:309-663-5582
Mailing Address - Fax:309-663-4683
Practice Address - Street 1:2103 E WASHINGTON ST STE 2D
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4365
Practice Address - Country:US
Practice Address - Phone:309-663-5582
Practice Address - Fax:309-663-4683
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019019178122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist