Stephen T Liesen, DMD
Individual provider Active NPI Dentist · Barry, IL
NPI 1124009329 · NPPES record last updated Oct 8, 2012
Key facts
- NPI
- 1124009329
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 19021224 (IL)
- Practice address
- 750 Mortimer St
Barry, IL 62312-1247 - Phone
- (217) 335-2397
- Fax
- (217) 335-2398
- NPI assigned
- Nov 7, 2005
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 19021224 | IL | MD | Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Barry Dental Clinic | Dentist | Past | Accepting new patients |
| Barry Dental Care PLCC | Past |
Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 19021224 | IL | Yes |
Addresses
Primary practice location
750 Mortimer St
Barry, IL 62312-1247
Mailing address
750 Mortimer St
Barry, IL 62312-1247
Phone (217) 335-2397
Other names
- Stephen T Liesen
Other providers in Barry, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 8, 2012. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.