Healthcare Provider Details

I. General information

NPI: 1023643301
Provider Name (Legal Business Name): AVERY MARC LIEBERMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2020
Last Update Date: 03/07/2020
Certification Date: 03/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 PARNASSUS AVE
SAN FRANCISCO CA
94143-2210
US

IV. Provider business mailing address

3 HACIENDA DR
TIBURON CA
94920-1134
US

V. Phone/Fax

Practice location:
  • Phone: 415-512-5800
  • Fax:
Mailing address:
  • Phone: 415-260-8911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number34988
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: