Provider Demographics
NPI:1649392606
Name:LIBERTO, ELISA S (DMD)
Entity Type:Individual
Prefix:DR
First Name:ELISA
Middle Name:S
Last Name:LIBERTO
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 1:67 JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02888-1053
Mailing Address - Country:US
Mailing Address - Phone:401-781-8696
Mailing Address - Fax:401-781-8698
Practice Address - Street 1:67 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02888-1053
Practice Address - Country:US
Practice Address - Phone:401-781-8696
Practice Address - Fax:401-781-8698
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRIDEN024101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice