Provider Demographics
NPI:1114182862
Name:LIBERTY DENTAL, PLC
Entity Type:Organization
Organization Name:LIBERTY DENTAL, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-665-0481
Mailing Address - Street 1:3688 W LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-9056
Mailing Address - Country:US
Mailing Address - Phone:734-665-0481
Mailing Address - Fax:734-665-9134
Practice Address - Street 1:3688 W LIBERTY RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-9056
Practice Address - Country:US
Practice Address - Phone:734-665-0481
Practice Address - Fax:734-665-9134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010175341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty