Liesen, Matthew

Liesen, Matthew is an individual health care provider with primary practice located at 4517 N Rockwood Dr , Peoria IL 61615-3841. He recently has 2 registered licenses in different health care specialties including Dental Providers / Dental Public Health, Dental Providers / General Practice. Dental Providers / General Practice is his primary health care specialty. Liesen, Matthew can be contacted via phone (309) 688-0121.

Contact Information

Primary practice address
4517 N Rockwood Dr Peoria IL 61615-3841
Phone: (309) 688-0121
Fax: (309) 688-5643
Website:
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Health care specialties

SpecialtyCodeLicense #State
Dental Providers / Dental Public Health 1223D0001X 019.030226 Illinois
Dental Providers / General Practice 1223G0001X 019030226 Illinois

Profile Details

NPI number 1619350725
LBN Legal business name Liesen, Matthew
Credentials Doctor of Dental Medicine (DMD)
Entity Individual
Sole proprietor 1 No
Enumeration date Jul 7th, 2015
Last updated Jul 7th, 2021 - about 5 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1619350725 NPPES
Illinois Other 1851909345 PEORIA DENTAL CARE, LLC.

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