Provider Demographics
NPI:1386277374
Name:GRANT LISKE DDS PC
Entity type:Organization
Organization Name:GRANT LISKE DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:LISKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-789-9500
Mailing Address - Street 1:330 9TH ST
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:CA
Mailing Address - Zip Code:92065-2321
Mailing Address - Country:US
Mailing Address - Phone:760-789-9500
Mailing Address - Fax:760-789-5179
Practice Address - Street 1:330 9TH ST
Practice Address - Street 2:
Practice Address - City:RAMONA
Practice Address - State:CA
Practice Address - Zip Code:92065-2321
Practice Address - Country:US
Practice Address - Phone:760-789-9500
Practice Address - Fax:760-789-5179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty