Provider Demographics
NPI:1619474095
Name:LIEBERMAN, JORDAN ALEXANDER (DDS)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:ALEXANDER
Last Name:LIEBERMAN
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 1:110 WINOOSKI FALLS WAY UNIT 306
Mailing Address - Street 2:
Mailing Address - City:WINOOSKI
Mailing Address - State:VT
Mailing Address - Zip Code:05404-2283
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:62 MERCHANTS ROW
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495
Practice Address - Country:US
Practice Address - Phone:802-951-4008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016.0133871122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist