Provider Demographics
NPI:1730114232
Name:SHORE PEDIATRIC DENTAL GROUP
Entity Type:Organization
Organization Name:SHORE PEDIATRIC DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:LIEBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:732-842-5577
Mailing Address - Street 1:152 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-2046
Mailing Address - Country:US
Mailing Address - Phone:732-842-5577
Mailing Address - Fax:732-842-8253
Practice Address - Street 1:152 BROAD ST
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-2046
Practice Address - Country:US
Practice Address - Phone:732-842-5577
Practice Address - Fax:732-842-8253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty