Provider Demographics
NPI:1336220821
Name:LISS, RONALD (DDS)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:LISS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 GRAND CANYON PARKWAY
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169-1705
Mailing Address - Country:US
Mailing Address - Phone:847-519-0600
Mailing Address - Fax:847-519-0693
Practice Address - Street 1:1000 GRAND CANYON PARKWAY
Practice Address - Street 2:SUITE 106
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-1705
Practice Address - Country:US
Practice Address - Phone:847-519-0600
Practice Address - Fax:847-519-0693
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190228821223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31552OtherBLUE CROSS BLUE SHIELD
IL388910Medicare ID - Type Unspecified
IL31552OtherBLUE CROSS BLUE SHIELD