Individual
DR. MATTHEW LIESEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
4517 N ROCKWOOD DR, PEORIA, IL 61615-3841
(309) 688-0121
(309) 688-5643
Mailing address
4517 N ROCKWOOD DR, PEORIA, IL 61615-3841
(309) 688-0121
(096) 885-6433
Taxonomy
Speciality
Code
Description
License number
State
1223D0001X
Public Health Dentistry
019.030226
IL
1223G0001X
General Practice Dentistry
Primary
019030226
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1851909345
PEORIA DENTAL CARE, LLC.
IL
Enumeration date
07/07/2015
Last updated
07/07/2021
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