Provider Demographics
NPI:1871044347
Name:LIBERTY DENTAL CARE & DENTURES-LLC
Entity Type:Organization
Organization Name:LIBERTY DENTAL CARE & DENTURES-LLC
Other - Org Name:LIBERTY DENTAL CARE & DENTURES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KHALID
Authorized Official - Middle Name:RASHID
Authorized Official - Last Name:CHAUDRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-815-6369
Mailing Address - Street 1:7100 SENNET PLACE
Mailing Address - Street 2:SUITE E
Mailing Address - City:LIBERTY TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:45069
Mailing Address - Country:US
Mailing Address - Phone:917-815-6369
Mailing Address - Fax:
Practice Address - Street 1:7100 SENNET PL
Practice Address - Street 2:SUITE E
Practice Address - City:LIBERTY TOWNSHP
Practice Address - State:OH
Practice Address - Zip Code:45069-1794
Practice Address - Country:US
Practice Address - Phone:917-815-6369
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-022036122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH310994808057OtherCARE SOURCE
OH2525959Medicaid