Provider Demographics
NPI:1588771489
Name:LIESINGER, ALAN WILLIAM (DMD)
Entity type:Individual
Prefix:DR
First Name:ALAN
Middle Name:WILLIAM
Last Name:LIESINGER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1813 WEST HARVARD AVE.
Mailing Address - Street 2:SUITE 240
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-8708
Mailing Address - Country:US
Mailing Address - Phone:541-440-9175
Mailing Address - Fax:541-440-6319
Practice Address - Street 1:375 PARK AVE.
Practice Address - Street 2:SUITE 7
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420
Practice Address - Country:US
Practice Address - Phone:541-440-9175
Practice Address - Fax:514-673-1246
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR55451223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
168369OtherWELFARE PROVIDER