Provider Demographics
NPI:1245407444
Name:NORTH LIBERTY DENTAL SERVICES P.C.
Entity Type:Organization
Organization Name:NORTH LIBERTY DENTAL SERVICES P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:BEIREIS
Authorized Official - Last Name:CARNEOL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:319-626-2300
Mailing Address - Street 1:525 W CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-9797
Mailing Address - Country:US
Mailing Address - Phone:319-626-2300
Mailing Address - Fax:319-626-3503
Practice Address - Street 1:525 W CHERRY ST
Practice Address - Street 2:
Practice Address - City:NORTH LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52317-9797
Practice Address - Country:US
Practice Address - Phone:319-626-2300
Practice Address - Fax:319-626-3503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA07594122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0179390Medicaid
IA49921OtherFEDERAL ID