Provider Demographics
NPI:1912281098
Name:DONALD R. LIBERTY, DDS, INC.
Entity Type:Organization
Organization Name:DONALD R. LIBERTY, DDS, INC.
Other - Org Name:GOLDEN FOOTHILLS ORAL AND FACIAL SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:LIBERTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-941-9860
Mailing Address - Street 1:4913 GOLDEN FOOTHILL PKWY
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-9636
Mailing Address - Country:US
Mailing Address - Phone:916-941-9860
Mailing Address - Fax:916-941-7165
Practice Address - Street 1:4913 GOLDEN FOOTHILL PKWY
Practice Address - Street 2:
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-9636
Practice Address - Country:US
Practice Address - Phone:916-941-9860
Practice Address - Fax:916-941-7165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA534661223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty