Provider Demographics
NPI:1811096282
Name:LIEDTKE, JOHN DAVID (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:LIEDTKE
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:PO BOX 905
Mailing Address - Street 2:
Mailing Address - City:GARRISON
Mailing Address - State:TX
Mailing Address - Zip Code:75946-0905
Mailing Address - Country:US
Mailing Address - Phone:936-347-2163
Mailing Address - Fax:936-347-2088
Practice Address - Street 1:593 HWY 59 SOUTH
Practice Address - Street 2:
Practice Address - City:GARRISON
Practice Address - State:TX
Practice Address - Zip Code:75996-0905
Practice Address - Country:US
Practice Address - Phone:936-347-2163
Practice Address - Fax:936-347-2088
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10424122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist