Provider Demographics
NPI:1972060606
Name:LIEBERMAN, GABRIELLE MORGAN
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:MORGAN
Last Name:LIEBERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-9635
Mailing Address - Country:US
Mailing Address - Phone:516-458-6480
Mailing Address - Fax:
Practice Address - Street 1:3915 E LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:DOWNINGTOWN
Practice Address - State:PA
Practice Address - Zip Code:19335
Practice Address - Country:US
Practice Address - Phone:610-269-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-28
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PADS0441111223P0221X
MADN18590771223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program