1588771489 NPI number — DR. ALAN WILLIAM LIESINGER DMD

Table of content: DR. ALAN WILLIAM LIESINGER DMD (NPI 1588771489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588771489 NPI number — DR. ALAN WILLIAM LIESINGER DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIESINGER
Provider First Name:
ALAN
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588771489
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1813 WEST HARVARD AVE.
Provider Second Line Business Mailing Address:
SUITE 240
Provider Business Mailing Address City Name:
ROSEBURG
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97471-8708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-440-9175
Provider Business Mailing Address Fax Number:
541-440-6319

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
375 PARK AVE.
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
COOS BAY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-440-9175
Provider Business Practice Location Address Fax Number:
514-673-1246
Provider Enumeration Date:
08/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  5545 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 168369 . This is a "WELFARE PROVIDER" identifier . This identifiers is of the category "OTHER".




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