Provider Demographics
NPI:1023239324
Name:LIES STUTSMAN, DANIELLE M (DDS)
Entity type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:M
Last Name:LIES STUTSMAN
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 1:1801 CHARLTON CT
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-6464
Mailing Address - Country:US
Mailing Address - Phone:574-533-8934
Mailing Address - Fax:574-533-9487
Practice Address - Street 1:1801 CHARLTON CT
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-6464
Practice Address - Country:US
Practice Address - Phone:574-533-8934
Practice Address - Fax:574-533-9487
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120103621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice