Healthcare Provider Details

I. General information

NPI: 1174534788
Provider Name (Legal Business Name): MARK B LIEBERMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11645 WILSHIRE BLVD SUITE 1001
LOS ANGELES CA
90025-1708
US

IV. Provider business mailing address

11645 WILSHIRE BLVD SUITE 1001
LOS ANGELES CA
90025-1708
US

V. Phone/Fax

Practice location:
  • Phone: 310-826-7863
  • Fax: 310-820-6163
Mailing address:
  • Phone: 310-826-7863
  • Fax: 310-820-6163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number22637
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: