Provider Demographics
NPI:1255458089
Name:LIEBAU, KRISTI A (DMD)
Entity type:Individual
Prefix:DR
First Name:KRISTI
Middle Name:A
Last Name:LIEBAU
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 E LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16511-1353
Mailing Address - Country:US
Mailing Address - Phone:814-899-3791
Mailing Address - Fax:814-899-0951
Practice Address - Street 1:4010 E LAKE RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16511-1353
Practice Address - Country:US
Practice Address - Phone:814-899-3791
Practice Address - Fax:814-899-0951
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS030937L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice