Provider Demographics
NPI:1588710552
Name:LIBERTY PARK DENTAL
Entity type:Organization
Organization Name:LIBERTY PARK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:DIXSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-415-8080
Mailing Address - Street 1:1508 NE 96TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-1348
Mailing Address - Country:US
Mailing Address - Phone:816-415-8080
Mailing Address - Fax:816-415-8083
Practice Address - Street 1:1508 NE 96TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-1348
Practice Address - Country:US
Practice Address - Phone:816-415-8080
Practice Address - Fax:816-415-8083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO015821122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty