Provider Demographics
NPI:1952452831
Name:TIESZEN, DENNIS D (OD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:D
Last Name:TIESZEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 HOME PLZ
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-4822
Mailing Address - Country:US
Mailing Address - Phone:319-236-0815
Mailing Address - Fax:
Practice Address - Street 1:999 HOME PLZ
Practice Address - Street 2:SUITE 100
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-4822
Practice Address - Country:US
Practice Address - Phone:319-236-0815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01790152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0117267Medicaid
IA18418OtherBLUE CROSS BLUE SHIELD
IA410030429OtherMEDICARE ID
IACG4244OtherMEDICARE ID
IA410030429OtherMEDICARE ID
IA0358460003Medicare NSC
IAT01141Medicare UPIN
IA0117267Medicaid