Provider Demographics
NPI:1497072094
Name:LIBERTY DENTAL, INC.
Entity Type:Organization
Organization Name:LIBERTY DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:CAMERON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:580-654-1008
Mailing Address - Street 1:P.O. BOX 365
Mailing Address - Street 2:
Mailing Address - City:CARNEGIE
Mailing Address - State:OK
Mailing Address - Zip Code:73015
Mailing Address - Country:US
Mailing Address - Phone:580-654-1008
Mailing Address - Fax:580-654-2008
Practice Address - Street 1:6 N. BROADWAY
Practice Address - Street 2:
Practice Address - City:CARNEGIE
Practice Address - State:OK
Practice Address - Zip Code:73015
Practice Address - Country:US
Practice Address - Phone:580-654-1008
Practice Address - Fax:580-654-2008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK59401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty