Healthcare Provider Details

I. General information

NPI: 1710940762
Provider Name (Legal Business Name): JACK LAWRENCE LIEBERMAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 N MILWAUKEE AVE SUITE1MS
CHICAGO IL
60630-1272
US

IV. Provider business mailing address

5400 N MILWAUKEE AVE SUITE1MS
CHICAGO IL
60630-1272
US

V. Phone/Fax

Practice location:
  • Phone: 773-774-4121
  • Fax: 773-774-4123
Mailing address:
  • Phone: 773-774-4121
  • Fax: 773-774-4123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number01912631
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: