MEDICARE: AYALA LIEBERMAN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	060764	NY

General Provider Information

NPI Number	:	1164923561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AYALA LIEBERMAN DDS

Provider Business Mailing Address
First Line	:	27005 76TH AVE
Second Line	:
City	:	NEW HYDE PARK
State	:	NY
Zip	:	11040-1402
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1420 AVENUE P
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-1189
Country	:	US
Telephone Number	:	718-339-7878
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2018
Last Update Date	:	09/18/2019

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