Provider Demographics
NPI:1992955306
Name:LIBERTY DENTAL GROUP
Entity type:Organization
Organization Name:LIBERTY DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:R.
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:KREY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:925-634-3501
Mailing Address - Street 1:6440 BRENTWOOD BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-2190
Mailing Address - Country:US
Mailing Address - Phone:925-634-3501
Mailing Address - Fax:925-634-1539
Practice Address - Street 1:6440 BRENTWOOD BLVD STE B
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-2190
Practice Address - Country:US
Practice Address - Phone:925-634-3501
Practice Address - Fax:925-634-1539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-22
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16705261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental