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General NPI Number Information
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NPI Number | 1700161338
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Entity Type | Organization
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Legal Business Name | LIBERTY 786 DENTISTRY
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Dates
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Enumeration Date | 10/14/2011
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Last Update Date | 10/14/2011
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Provider Practice Location Address
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Address Line | 11302 LIBERTY AVE
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City | SOUTH RICHMOND HILL
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State | NY
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Zip | 11419-1808
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Country | US
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Telephone | 718-322-4200
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Fax | 718-322-1144
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Provider Business Mailing Address
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Address Line | 11302 LIBERTY AVE
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City | SOUTH RICHMOND HILL
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State | NY
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Zip | 11419-1808
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Country | US
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Telephone | 718-322-4200
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Fax | 718-322-1144
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Authorized Official
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Title or Position | D.D.S
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Name | DR. RBEEA M KHAN
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Credential |
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Telephone | 718-322-4200
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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 | 054968-1
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License Number State | NY
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