Provider Demographics
NPI:1003269358
Name:LIDDIARD, JEREMY JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:JOHN
Last Name:LIDDIARD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12005 N TATUM BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-1650
Mailing Address - Country:US
Mailing Address - Phone:602-971-0026
Mailing Address - Fax:
Practice Address - Street 1:12005 N TATUM BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-1650
Practice Address - Country:US
Practice Address - Phone:602-971-0026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009550122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist