Provider Demographics
NPI:1316483050
Name:LIEBOLD DENTAL PLLC
Entity type:Organization
Organization Name:LIEBOLD DENTAL PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:LIEBOLD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-228-2200
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:BOTTINEAU
Mailing Address - State:ND
Mailing Address - Zip Code:58318-0369
Mailing Address - Country:US
Mailing Address - Phone:701-228-2200
Mailing Address - Fax:701-228-2222
Practice Address - Street 1:210 11TH ST E
Practice Address - Street 2:
Practice Address - City:BOTTINEAU
Practice Address - State:ND
Practice Address - Zip Code:58318-2052
Practice Address - Country:US
Practice Address - Phone:701-228-2200
Practice Address - Fax:701-228-2222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND1758122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty