MEDICARE: LIBERTY 786 DENTISTRY

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	054968-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700161338
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY 786 DENTISTRY

Provider Business Mailing Address
First Line	:	11302 LIBERTY AVE
Second Line	:
City	:	SOUTH RICHMOND HILL
State	:	NY
Zip	:	11419-1808
Country	:	US
Telephone Number	:	718-322-4200
Fax Number	:	718-322-1144

Provider Business Practice Location Address
First Line	:	11302 LIBERTY AVE
Second Line	:
City	:	SOUTH RICHMOND HILL
State	:	NY
Zip	:	11419-1808
Country	:	US
Telephone Number	:	718-322-4200
Fax Number	:	718-322-1144

Authorized Official
Title or Position	:	D.D.S
Name	:	DR. RBEEA M KHAN
Credential	:
Telephone Number	:	718-322-4200

Provider Enumeration Date	:	10/14/2011
Last Update Date	:	10/14/2011

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