Provider Demographics
NPI:1700134749
Name:LISA KONZ, D.D.S., P.C.
Entity Type:Organization
Organization Name:LISA KONZ, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF PROFESSIONAL CORPORATI
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KONZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-367-3050
Mailing Address - Street 1:747 N. MILWAUKEE AVE.
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048
Mailing Address - Country:US
Mailing Address - Phone:847-367-3050
Mailing Address - Fax:847-367-3053
Practice Address - Street 1:747 N. MILWAUKEE AVE.
Practice Address - Street 2:SUITE 103
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048
Practice Address - Country:US
Practice Address - Phone:847-367-3050
Practice Address - Fax:847-367-3053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-23
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0247561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty