Healthcare Provider Details

I. General information

NPI: 1316483050
Provider Name (Legal Business Name): LIEBOLD DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 11TH ST E
BOTTINEAU ND
58318-2052
US

IV. Provider business mailing address

PO BOX 369
BOTTINEAU ND
58318-0369
US

V. Phone/Fax

Practice location:
  • Phone: 701-228-2200
  • Fax: 701-228-2222
Mailing address:
  • Phone: 701-228-2200
  • Fax: 701-228-2222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberND1758
License Number StateND

VIII. Authorized Official

Name: DAVID A. LIEBOLD
Title or Position: DIRECTOR
Credential: DDS
Phone: 701-228-2200