MEDICARE: DONALD R. LIBERTY, DDS, INC.

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	:	1912281098
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DONALD R. LIBERTY, DDS, INC.

Provider Business Mailing Address
First Line	:	4913 GOLDEN FOOTHILL PKWY
Second Line	:
City	:	EL DORADO HILLS
State	:	CA
Zip	:	95762-9636
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	:	95762-9636
Country	:	US
Telephone Number	:	916-941-9860
Fax Number	:	916-941-7165

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DONALD ROBERT LIBERTY
Credential	:	D.D.S.
Telephone Number	:	916-941-9860

Provider Enumeration Date	:	10/06/2011
Last Update Date	:	10/06/2011

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