Provider Demographics
NPI:1568711257
Name:ALAN LIESINGER DMD PC
Entity Type:Organization
Organization Name:ALAN LIESINGER DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:LIESINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-269-2329
Mailing Address - Street 1:375 PARK AVE., SUITE 7
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2242
Mailing Address - Country:US
Mailing Address - Phone:541-267-2329
Mailing Address - Fax:541-267-4026
Practice Address - Street 1:375 PARK AVE., SUITE 7
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2242
Practice Address - Country:US
Practice Address - Phone:541-267-2329
Practice Address - Fax:541-267-4026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-10
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6675951223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
168369OtherWELFARE PROVIDER #