Provider Demographics
NPI:1285121400
Name:LIBERTY DENTAL PLAN OF NEW YORK, INC.
Entity type:Organization
Organization Name:LIBERTY DENTAL PLAN OF NEW YORK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARVELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-703-6999
Mailing Address - Street 1:340 COMMERCE STE 100
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-1358
Mailing Address - Country:US
Mailing Address - Phone:888-703-6999
Mailing Address - Fax:
Practice Address - Street 1:340 COMMERCE STE 100
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92602
Practice Address - Country:US
Practice Address - Phone:888-703-6999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIBERTY DENTAL PLAN CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-13
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYXXXX302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYXXXXMedicaid