Provider Demographics
NPI:1306924980
Name:LIBERTY, DONALD R (DDS)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:R
Last Name:LIBERTY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:95762-9632
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
Practice Address - Country:US
Practice Address - Phone:916-941-9860
Practice Address - Fax:916-941-7165
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA534661223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
V07149Medicare UPIN
DSO534660Medicare ID - Type Unspecified