Provider Demographics
NPI:1104121698
Name:LISNICH, ANN MARIE (DDS)
Entity type:Individual
Prefix:MRS
First Name:ANN MARIE
Middle Name:
Last Name:LISNICH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 W. GARTNER ROAD
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540
Mailing Address - Country:US
Mailing Address - Phone:630-369-8000
Mailing Address - Fax:
Practice Address - Street 1:8 W. GARTNER ROAD
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540
Practice Address - Country:US
Practice Address - Phone:630-369-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-14
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.024264122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist