Provider Demographics
NPI:1437847654
Name:INTERLACHEN DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:INTERLACHEN DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LIBERKO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-920-9579
Mailing Address - Street 1:5101 VERNON AVE S
Mailing Address - Street 2:STE 1B
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55436-2171
Mailing Address - Country:US
Mailing Address - Phone:952-920-9579
Mailing Address - Fax:952-920-9298
Practice Address - Street 1:5101 VERNON AVE S
Practice Address - Street 2:STE 1B
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55436-2171
Practice Address - Country:US
Practice Address - Phone:952-920-9579
Practice Address - Fax:952-920-9298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty