Provider Demographics
NPI:1184703316
Name:LIBERTY HILL DENTAL PA
Entity type:Organization
Organization Name:LIBERTY HILL DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THAD
Authorized Official - Middle Name:H
Authorized Official - Last Name:GILLESPIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-515-0171
Mailing Address - Street 1:14933 W STATE HWY 29
Mailing Address - Street 2:
Mailing Address - City:LIBERTY HILL
Mailing Address - State:TX
Mailing Address - Zip Code:78642
Mailing Address - Country:US
Mailing Address - Phone:512-515-0171
Mailing Address - Fax:512-515-0042
Practice Address - Street 1:14933 W STATE HWY 29
Practice Address - Street 2:
Practice Address - City:LIBERTY HILL
Practice Address - State:TX
Practice Address - Zip Code:78642
Practice Address - Country:US
Practice Address - Phone:512-515-0171
Practice Address - Fax:512-515-0042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
81265501OtherCHIP