Provider Demographics
NPI:1831683168
Name:GREGG LIEDTKA DMD PLLC
Entity type:Organization
Organization Name:GREGG LIEDTKA DMD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:NINA
Authorized Official - Middle Name:
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-431-4313
Mailing Address - Street 1:PO BOX 429
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:WA
Mailing Address - Zip Code:99159-0429
Mailing Address - Country:US
Mailing Address - Phone:509-982-2605
Mailing Address - Fax:
Practice Address - Street 1:20 W 1ST AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:WA
Practice Address - Zip Code:99159
Practice Address - Country:US
Practice Address - Phone:209-982-2605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-20
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00008440122300000X
WADE00010090122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA604262185OtherSTATE OF WASHINGTON UBI