Provider Demographics
NPI:1417097007
Name:LIEBOLD, DAVID ALLAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ALLAN
Last Name:LIEBOLD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOTTINEAU
Mailing Address - State:ND
Mailing Address - Zip Code:58318-1344
Mailing Address - Country:US
Mailing Address - Phone:701-228-2200
Mailing Address - Fax:
Practice Address - Street 1:621 MAIN ST
Practice Address - Street 2:
Practice Address - City:BOTTINEAU
Practice Address - State:ND
Practice Address - Zip Code:58318-1344
Practice Address - Country:US
Practice Address - Phone:701-228-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND17581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41105Medicaid