Healthcare Provider Details

I. General information

NPI: 1649516295
Provider Name (Legal Business Name): LIBERTY DENTAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2012
Last Update Date: 12/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 W ADAMS ST
HAVANA IL
62644-1337
US

IV. Provider business mailing address

112 W ADAMS ST
HAVANA IL
62644-1337
US

V. Phone/Fax

Practice location:
  • Phone: 309-543-6301
  • Fax: 309-543-4958
Mailing address:
  • Phone: 309-543-6301
  • Fax: 309-543-4958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019024184
License Number StateIL

VIII. Authorized Official

Name: DR. AARON JAMES BLAKELY
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 309-543-6301