MEDICARE: DONALD R. LIBERTY 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	53466	CA

General Provider Information

NPI Number	:	1306924980
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONALD R. LIBERTY DDS

Provider Business Mailing Address
First Line	:	4913 GOLDEN FOOTHILL PKWY
Second Line	:
City	:	EL DORADO HILLS
State	:	CA
Zip	:	95762-9632
Country	:	US
Telephone Number	:	916-941-9860
Fax Number	:	916-941-7165

Provider Business Practice Location Address
First Line	:	4913 GOLDEN FOOTHILL PKWY
Second Line	:
City	:	EL DORADO HILLS
State	:	CA
Zip	:	95762
Country	:	US
Telephone Number	:	916-941-9860
Fax Number	:	916-941-7165

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

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	07/19/2018

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