Healthcare Provider Details

I. General information

NPI: 1346340817
Provider Name (Legal Business Name): DRS. ED & SUE LIEBENTHAL PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 W.SOUTH ST.
HARTFORD MI
49057
US

IV. Provider business mailing address

19 W.SOUTH ST.
HARTFORD MI
49057
US

V. Phone/Fax

Practice location:
  • Phone: 269-621-6441
  • Fax:
Mailing address:
  • Phone: 269-621-6441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberMI14227
License Number StateMI

VIII. Authorized Official

Name: DR. EDWARD W. LIEBENTHAL
Title or Position: OWNER
Credential: D.D.S.
Phone: 269-621-6441