Healthcare Provider Details

I. General information

NPI: 1861541690
Provider Name (Legal Business Name): DARRYL ERIK LIEBERMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 CONCOURSE VLG W
BRONX NY
10451-3804
US

IV. Provider business mailing address

790 CONCOURSE VLG W
BRONX NY
10451-3804
US

V. Phone/Fax

Practice location:
  • Phone: 718-538-6060
  • Fax: 718-538-4833
Mailing address:
  • Phone: 718-538-6060
  • Fax: 718-538-4833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number044003
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: