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
State | License ID | Taxonomies |
---|---|---|
IA | 01790 | 152W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 152W00000X | Eye and Vision Services Providers | Optometrist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IA | 0117267 | Medicaid | |
IA | 18418 | Other | BLUE CROSS BLUE SHIELD |
IA | 410030429 | Other | MEDICARE ID |
IA | CG4244 | Other | MEDICARE ID |
IA | 410030429 | Other | MEDICARE ID |
IA | 0358460003 | Medicare NSC | |
IA | T01141 | Medicare UPIN | |
IA | 0117267 | Medicaid |