Organization
GREGG LIEDTKA DMD PLLC
Active
Other names
Odessa Dental Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. NINA STEWART (ADMINISTRATIVE ASSISTANT)
(520) 431-4313
Entity
Organization
Contact information
Practice address
20 W 1ST AVE, ODESSA, WA 99159
(209) 982-2605
Mailing address
PO BOX 429, ODESSA, WA 99159-0429
(509) 982-2605
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
DE00008440
WA
122300000X
Dentist
Primary
DE00010090
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
604262185
STATE OF WASHINGTON UBI
WA
Enumeration date
06/20/2018
Last updated
07/03/2018
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