Healthcare Provider Details

I. General information

NPI: 1447464060
Provider Name (Legal Business Name): SUE EILEEN LIEBENTHAL D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 W SOUTH ST
HARTFORD MI
49057-1236
US

IV. Provider business mailing address

19 W SOUTH ST
HARTFORD MI
49057-1236
US

V. Phone/Fax

Practice location:
  • Phone: 269-621-6441
  • Fax: 269-621-3579
Mailing address:
  • Phone: 269-621-6441
  • Fax: 269-621-3579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14228
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: