Healthcare Provider Details

I. General information

NPI: 1639663578
Provider Name (Legal Business Name): ALYSSA LIEBZEIT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

437 BOYLSTON ST FL 5
BOSTON MA
02116-3307
US

IV. Provider business mailing address

437 BOYLSTON ST FL 5
BOSTON MA
02116-3307
US

V. Phone/Fax

Practice location:
  • Phone: 781-729-5055
  • Fax: 617-927-1112
Mailing address:
  • Phone: 781-729-5055
  • Fax: 617-927-1112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1857965
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: