Provider Demographics
NPI:1265054332
Name:LIESTMAN, MARI
Entity type:Individual
Prefix:
First Name:MARI
Middle Name:
Last Name:LIESTMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 NORTHDALE BLVD NW UNIT 240
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2996
Mailing Address - Country:US
Mailing Address - Phone:320-217-9940
Mailing Address - Fax:
Practice Address - Street 1:201 SANDBERG RD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8906
Practice Address - Country:US
Practice Address - Phone:763-295-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MND14650122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program