Healthcare Provider Details

I. General information

NPI: 1750848412
Provider Name (Legal Business Name): LIBERTY DENTAL PLAN EAST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2019
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 FLIGHT WAY STE 125
TUSTIN CA
92782-1828
US

IV. Provider business mailing address

1730 FLIGHT WAY STE 125
TUSTIN CA
92782-1828
US

V. Phone/Fax

Practice location:
  • Phone: 888-703-6999
  • Fax:
Mailing address:
  • Phone: 888-703-6999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: MARZENA FERCZ
Title or Position: CHIEF COMPLIANCE OFFICER
Credential:
Phone: 888-703-6999