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General NPI Number Information
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NPI Number | 1699938589
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Entity Type | Organization
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Legal Business Name | LIBERTY CORNERS DENTAL PLLC
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Dates
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Enumeration Date | 07/09/2008
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Last Update Date | 07/09/2008
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Provider Practice Location Address
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Address Line | 7298 JACKMAN RD
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City | TEMPERANCE
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State | MI
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Zip | 48182-1313
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Country | US
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Telephone | 734-847-6350
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Fax |
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Provider Business Mailing Address
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Address Line | 7298 JACKMAN RD
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City | TEMPERANCE
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State | MI
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Zip | 48182-1313
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Country | US
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Telephone | 734-847-6350
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | LARRY MIZELLE
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Credential |
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Telephone | 734-847-6350
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2901010910
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License Number State | MI
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