Provider Demographics
NPI:1376862953
Name:LIBERTY DENTURE CLINIC, LLC
Entity Type:Organization
Organization Name:LIBERTY DENTURE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTURIST
Authorized Official - Prefix:
Authorized Official - First Name:OSWALDO
Authorized Official - Middle Name:GONZALEZ
Authorized Official - Last Name:CANTARERO
Authorized Official - Suffix:
Authorized Official - Credentials:LD
Authorized Official - Phone:503-363-0629
Mailing Address - Street 1:1678 LIBERTY ST SE
Mailing Address - Street 2:SUITE #202
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4348
Mailing Address - Country:US
Mailing Address - Phone:503-363-0629
Mailing Address - Fax:
Practice Address - Street 1:1678 LIBERTY ST SE
Practice Address - Street 2:SUITE #202
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4348
Practice Address - Country:US
Practice Address - Phone:503-363-0629
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-22
Last Update Date:2010-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-DO-10122043261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental