Provider Demographics
NPI:1841404449
Name:LIEBENTHAL, EDWARD WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:WILLIAM
Last Name:LIEBENTHAL
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 1:19 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49057-1236
Mailing Address - Country:US
Mailing Address - Phone:269-621-6441
Mailing Address - Fax:269-621-3579
Practice Address - Street 1:19 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:MI
Practice Address - Zip Code:49057-1236
Practice Address - Country:US
Practice Address - Phone:269-621-6441
Practice Address - Fax:269-621-3579
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI142271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice