Provider Demographics
NPI:1407187388
Name:PINEBROOK DENTAL CARE CORP DENTAL OFFICE OF DIANE C. LIBERTY, DDS CORP
Entity Type:Organization
Organization Name:PINEBROOK DENTAL CARE CORP DENTAL OFFICE OF DIANE C. LIBERTY, DDS CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:B
Authorized Official - Last Name:CARANDANG-LIBERTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-988-7790
Mailing Address - Street 1:8008 FOLSOM AUBURN RD
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-1664
Mailing Address - Country:US
Mailing Address - Phone:916-988-7790
Mailing Address - Fax:916-988-5447
Practice Address - Street 1:8008 FOLSOM AUBURN RD
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-1664
Practice Address - Country:US
Practice Address - Phone:916-988-7790
Practice Address - Fax:916-988-5447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-16
Last Update Date:2010-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA533771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty