Provider Demographics
NPI:1255196119
Name:LIBERTY FAMILY DENTAL, PC
Entity type:Organization
Organization Name:LIBERTY FAMILY DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMON
Authorized Official - Middle Name:IVAN
Authorized Official - Last Name:LUGO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:267-226-6070
Mailing Address - Street 1:104 FULTON AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-2808
Mailing Address - Country:US
Mailing Address - Phone:267-226-6070
Mailing Address - Fax:
Practice Address - Street 1:104 FULTON AVE FL 2
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-2808
Practice Address - Country:US
Practice Address - Phone:267-226-6070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty