Provider Demographics
NPI:1528172343
Name:LYNDON L. LIEBELT, DDS, PA
Entity type:Organization
Organization Name:LYNDON L. LIEBELT, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYNDON
Authorized Official - Middle Name:L
Authorized Official - Last Name:LIEBELT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-296-6100
Mailing Address - Street 1:10555 MONTGOMERY BLVD NE
Mailing Address - Street 2:SUITE 70
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3857
Mailing Address - Country:US
Mailing Address - Phone:505-296-6100
Mailing Address - Fax:505-271-5490
Practice Address - Street 1:10555 MONTGOMERY BLVD NE
Practice Address - Street 2:SUITE 70
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3857
Practice Address - Country:US
Practice Address - Phone:505-296-6100
Practice Address - Fax:505-271-5490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD13011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty