Provider Demographics
NPI:1912288846
Name:LIBERMAN, GINA T
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:T
Last Name:LIBERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:694 CHIPPEWA CIR
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60073-1181
Mailing Address - Country:US
Mailing Address - Phone:847-774-3748
Mailing Address - Fax:
Practice Address - Street 1:694 CHIPPEWA CIR
Practice Address - Street 2:
Practice Address - City:ROUND LAKE HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60073-1181
Practice Address - Country:US
Practice Address - Phone:847-774-3748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020.013763124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist