Provider Demographics
NPI:1407856156
Name:LIEBLICK, RUSSELL ARON (DMD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:ARON
Last Name:LIEBLICK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24850 SE STARK ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-8316
Mailing Address - Country:US
Mailing Address - Phone:503-665-7882
Mailing Address - Fax:503-665-6983
Practice Address - Street 1:24850 SE STARK ST
Practice Address - Street 2:SUITE 100
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-8316
Practice Address - Country:US
Practice Address - Phone:503-665-7882
Practice Address - Fax:503-665-6983
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD83421223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery