Provider Demographics
NPI:1700989381
Name:LIES, MARK JOHN (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOHN
Last Name:LIES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PARK DR S
Mailing Address - Street 2:STE 203
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405
Mailing Address - Country:US
Mailing Address - Phone:406-453-6459
Mailing Address - Fax:406-453-6466
Practice Address - Street 1:300 PARK DR S
Practice Address - Street 2:STE 203
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405
Practice Address - Country:US
Practice Address - Phone:406-453-6459
Practice Address - Fax:406-453-6466
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT17551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT048217Medicaid