Provider Demographics
NPI:1437771961
Name:LEIBMAN, MALLORY JANE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:JANE
Last Name:LEIBMAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 S HIGHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-1511
Mailing Address - Country:US
Mailing Address - Phone:201-469-7386
Mailing Address - Fax:
Practice Address - Street 1:88 W RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3199
Practice Address - Country:US
Practice Address - Phone:201-652-8875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-06
Last Update Date:2021-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI02853600122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program