Healthcare Provider Details

I. General information

NPI: 1316958929
Provider Name (Legal Business Name): MARK B LIEBERMAN DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 08/22/2020
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 Code261QD0000X
TaxonomyDental Clinic/Center
License Number22637
License Number StateCA

VIII. Authorized Official

Name: DR. MARK B LIEBERMAN
Title or Position: PRESIDENT
Credential: DDS
Phone: 310-826-7863