Healthcare Provider Details

I. General information

NPI: 1679527972
Provider Name (Legal Business Name): JACOB LIEBERMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 POLY PL
BROOKLYN NY
11209-7104
US

IV. Provider business mailing address

2168 E 26TH ST
BROOKLYN NY
11229-4955
US

V. Phone/Fax

Practice location:
  • Phone: 718-836-6600
  • Fax:
Mailing address:
  • Phone: 718-769-3497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number033261
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: