Provider Demographics
NPI:1720577448
Name:LIBERTY INDIANA ALEXANDRUNAS
Entity Type:Organization
Organization Name:LIBERTY INDIANA ALEXANDRUNAS
Other - Org Name:PREMIER DENTAL OF LIBERTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEXANDRUNAS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:614-425-9061
Mailing Address - Street 1:3363 KITZMILLER RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-8542
Mailing Address - Country:US
Mailing Address - Phone:614-935-7677
Mailing Address - Fax:
Practice Address - Street 1:302 S FAIRGROUND ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:IN
Practice Address - Zip Code:47353-1414
Practice Address - Country:US
Practice Address - Phone:614-935-7677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007652B122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty