Healthcare Provider Details

I. General information

NPI: 1003806878
Provider Name (Legal Business Name): MATTHEW M LIEBENTRITT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 MAIN STREET
SPRINGFIELD NE
68059-0328
US

IV. Provider business mailing address

PO BOX 328 191 MAIN STREET
SPRINGFIELD NE
68059-0328
US

V. Phone/Fax

Practice location:
  • Phone: 402-253-2868
  • Fax: 402-253-2881
Mailing address:
  • Phone: 402-253-2868
  • Fax: 402-253-2881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6123
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: