Provider Demographics
NPI:1619350725
Name:LIESEN, MATTHEW (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:LIESEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4517 N ROCKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-3841
Mailing Address - Country:US
Mailing Address - Phone:309-688-0121
Mailing Address - Fax:096-885-6433
Practice Address - Street 1:4517 N ROCKWOOD DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-3841
Practice Address - Country:US
Practice Address - Phone:309-688-0121
Practice Address - Fax:309-688-5643
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0302261223D0001X
IL0190302261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1851909345OtherPEORIA DENTAL CARE, LLC.