# GREGG LIEDTKA DMD PLLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Odessa Dental Clinic
- **Organization subpart:** No

## Provider details

- **NPI number:** 1831683168
- **Authorized official:** MRS. NINA STEWART (ADMINISTRATIVE ASSISTANT)
- **Authorized official phone:** (520) 431-4313

## Contact information

- **Practice address:** 20 W 1ST AVE, ODESSA, WA 99159
- **Practice address phone:** (209) 982-2605
- **Mailing address:** PO BOX 429, ODESSA, WA 99159-0429
- **Mailing address phone:** (509) 982-2605

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | DE00008440 | WA | — |
| 122300000X | Dentist | DE00010090 | WA | Yes |

## Other

- **Enumeration date:** 06/20/2018
- **Last updated:** 07/03/2018

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 604262185 | STATE OF WASHINGTON UBI | WA |