Provider Demographics
NPI:1659435253
Name:TIETJENS, KIIRI TAMM (DDS)
Entity Type:Individual
Prefix:
First Name:KIIRI
Middle Name:TAMM
Last Name:TIETJENS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 ALMAR PKWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-2315
Mailing Address - Country:US
Mailing Address - Phone:815-939-7136
Mailing Address - Fax:815-939-9820
Practice Address - Street 1:750 ALMAR PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2315
Practice Address - Country:US
Practice Address - Phone:815-939-7136
Practice Address - Fax:815-939-9820
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery