Provider Demographics
NPI:1184325243
Name:LIEBERMAN, JACQUELINE D (DMD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:D
Last Name:LIEBERMAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 4TH ST S UNIT 841
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4591
Mailing Address - Country:US
Mailing Address - Phone:610-955-2256
Mailing Address - Fax:
Practice Address - Street 1:51 MEDICAL GROUP
Practice Address - Street 2:UNIT 2060
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96278-2060
Practice Address - Country:US
Practice Address - Phone:850-883-8324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-15
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS044070122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist