Provider Demographics
NPI:1710940762
Name:LIEBERMAN, JACK LAWRENCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:LAWRENCE
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 1:5400 N MILWAUKEE AVE
Mailing Address - Street 2:SUITE1MS
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-1272
Mailing Address - Country:US
Mailing Address - Phone:773-774-4121
Mailing Address - Fax:773-774-4123
Practice Address - Street 1:5400 N MILWAUKEE AVE
Practice Address - Street 2:SUITE1MS
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-1272
Practice Address - Country:US
Practice Address - Phone:773-774-4121
Practice Address - Fax:773-774-4123
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019126311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1002718Medicaid