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General NPI Number Information
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NPI Number | 1376862953
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Entity Type | Organization
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Legal Business Name | LIBERTY DENTURE CLINIC, LLC
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Dates
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Enumeration Date | 05/22/2010
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Last Update Date | 05/22/2010
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Provider Practice Location Address
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Address Line | 1678 LIBERTY ST SE SUITE #202
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City | SALEM
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State | OR
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Zip | 97302-4348
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Country | US
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Telephone | 503-363-0629
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Fax |
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Provider Business Mailing Address
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Address Line | 1678 LIBERTY ST SE SUITE #202
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City | SALEM
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State | OR
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Zip | 97302-4348
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Country | US
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Telephone | 503-363-0629
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Fax |
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Authorized Official
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Title or Position | DENTURIST
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Name | OSWALDO GONZALEZ CANTARERO
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Credential | LD
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Telephone | 503-363-0629
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DT-DO-10122043
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License Number State | OR
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