Healthcare Provider Details

I. General information

NPI: 1932197019
Provider Name (Legal Business Name): GERALD B. LEIBER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

0 GOVERNORS AVE SUITE 30
MEDFORD MA
02155-3025
US

IV. Provider business mailing address

0 GOVERNORS AVE SUITE 30
MEDFORD MA
02155-3025
US

V. Phone/Fax

Practice location:
  • Phone: 781-391-5100
  • Fax: 781-391-4833
Mailing address:
  • Phone: 781-391-5100
  • Fax: 781-391-4833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12008
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: