Provider Demographics
NPI:1124505599
Name:LIBERTY PARK FAMILY DENTISTRY
Entity type:Organization
Organization Name:LIBERTY PARK FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:NUNES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:205-602-4533
Mailing Address - Street 1:3508 SPRINGHILL RD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN BRK
Mailing Address - State:AL
Mailing Address - Zip Code:35223-2013
Mailing Address - Country:US
Mailing Address - Phone:205-602-4533
Mailing Address - Fax:
Practice Address - Street 1:8000 LIBERTY PKWY STE 126
Practice Address - Street 2:
Practice Address - City:VESTAVIA
Practice Address - State:AL
Practice Address - Zip Code:35242-7565
Practice Address - Country:US
Practice Address - Phone:205-413-8116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5514261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental