=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508967217
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD JOEL LIEB DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 WELBORNE DR SUITE 202
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23229-5656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-741-2800
-----------------------------------------------------
Fax | 804-741-2834
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 WELBORNE DR SUITE 202
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23229-5656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 0401004965
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------