Healthcare Provider Details

I. General information

NPI: 1417954074
Provider Name (Legal Business Name): WILLIAM BENJAMIN LEIBOW D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4910 N 44TH ST STE 10
PHOENIX AZ
85018-2726
US

IV. Provider business mailing address

5516 N CAMELBACK CANYON DR
PHOENIX AZ
85018-1239
US

V. Phone/Fax

Practice location:
  • Phone: 602-840-3636
  • Fax:
Mailing address:
  • Phone: 602-840-8433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number2006
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: