Liberty Dental, Inc

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

019024184 Issued in IL

Legal business name

LIBERTY DENTAL, INC

Practice address

112 W Adams St
Havana, IL 62644-1337

Phone

(309) 543-6301

Fax

(309) 543-4958

NPI assigned

Dec 28, 2012

Last updated

Dec 28, 2012By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Aaron James Blakely, D.M.D.NPI 1215096037

Title

President

Phone

(309) 543-6301

Specialties & licenses 1

Addresses

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Aaron James Blakely, D.M.D.

  • General Practice Dentistry
  • Havana, IL
  • NPI 1215096037
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1356652800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1356652800000",
    "number": "1649516295",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "112 W ADAMS ST",
            "city": "HAVANA",
            "state": "IL",
            "postal_code": "626441337",
            "telephone_number": "309-543-6301",
            "fax_number": "309-543-4958"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "112 W ADAMS ST",
            "city": "HAVANA",
            "state": "IL",
            "postal_code": "626441337",
            "telephone_number": "309-543-6301",
            "fax_number": "309-543-4958"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIBERTY DENTAL, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-12-28",
        "last_updated": "2012-12-28",
        "status": "A",
        "authorized_official_last_name": "BLAKELY",
        "authorized_official_first_name": "AARON",
        "authorized_official_middle_name": "JAMES",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "309-543-6301",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.M.D."
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "IL",
            "license": "019024184",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jenna Elizabeth Ishmael, FNP-C
• Marsha R Kirchner, CF-NP
• Kelsey Elizabeth Knake
• Sarah Knake, RN-CDE
• Kelley D Lawless, COTA/L
• Ashley Marmon, FNP-C
• Mason County (Mason County Health Department)
• Mason County Health Department
• Mason District Hospital
• Mason District Hospital (Mason District Hospital Employee Pharmacy)

• General Practice Dentistry in Havana, IL
• Providers in Havana, IL by specialty
• General Practice Dentistry in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 28, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.