Provider Demographics
NPI:1346644176
Name:LIBERTY TRAILS ENDODONTICS, LLC
Entity Type:Organization
Organization Name:LIBERTY TRAILS ENDODONTICS, LLC
Other - Org Name:COASTAL ENDODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:LEA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:912-756-5960
Mailing Address - Street 1:111 E MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-2616
Mailing Address - Country:US
Mailing Address - Phone:912-463-4405
Mailing Address - Fax:912-463-4939
Practice Address - Street 1:111 E MILLS AVE
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-2616
Practice Address - Country:US
Practice Address - Phone:912-463-4405
Practice Address - Fax:912-463-4939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0130791223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty