Provider Demographics
NPI:1003195298
Name:LIBERTY DENTAL CARE P.C.
Entity Type:Organization
Organization Name:LIBERTY DENTAL CARE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEUNARINE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-322-1415
Mailing Address - Street 1:112-10 LIBERTY AVENUE
Mailing Address - Street 2:
Mailing Address - City:SOUTH RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11419
Mailing Address - Country:US
Mailing Address - Phone:718-322-1415
Mailing Address - Fax:718-880-2360
Practice Address - Street 1:11210 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11419-1814
Practice Address - Country:US
Practice Address - Phone:718-322-1415
Practice Address - Fax:718-880-2360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-05
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0533941223G0001X
NY0463411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02921479Medicaid
NY01742896Medicaid