Healthcare Provider Details

I. General information

NPI: 1679676712
Provider Name (Legal Business Name): LIBORIA MCDONALD GALLANT RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 26610 WUERZBURG DENTAL ACTIVITY CREDENTIALS OFFICE
APOAE NY
09244
US

IV. Provider business mailing address

UNIT 26610 WUERZBURG DENTAL ACTIVITY CREDENTIALS OFFICE
APOAE NY
09244
US

V. Phone/Fax

Practice location:
  • Phone: 931-804-3933
  • Fax:
Mailing address:
  • Phone: 931-804-3933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH005929
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: