Healthcare Provider Details

I. General information

NPI: 1164923561
Provider Name (Legal Business Name): AYALA LIEBERMAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2018
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 AVENUE P
BROOKLYN NY
11229-1189
US

IV. Provider business mailing address

27005 76TH AVE
NEW HYDE PARK NY
11040-1402
US

V. Phone/Fax

Practice location:
  • Phone: 718-339-7878
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number060764
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: