Provider Demographics
NPI:1881789287
Name:LIESEN, LAWRENCE JOHN I (DDS)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:JOHN
Last Name:LIESEN
Suffix:I
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 1:6N182 SUNSET DR.
Mailing Address - Street 2:
Mailing Address - City:ST. CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175
Mailing Address - Country:US
Mailing Address - Phone:630-443-0480
Mailing Address - Fax:
Practice Address - Street 1:6N182 SUNSET DR.
Practice Address - Street 2:
Practice Address - City:ST. CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175
Practice Address - Country:US
Practice Address - Phone:630-443-0480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice