Provider Demographics
NPI:1477005767
Name:LIBERTY DENTAL GROUP
Entity Type:Organization
Organization Name:LIBERTY DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:TUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-415-3866
Mailing Address - Street 1:6440 BRENTWOOD BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-5789
Mailing Address - Country:US
Mailing Address - Phone:925-634-3501
Mailing Address - Fax:925-634-1539
Practice Address - Street 1:6440 BRENTWOOD BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-5789
Practice Address - Country:US
Practice Address - Phone:925-634-3501
Practice Address - Fax:925-634-1539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA617061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty