Organization
LIBERTY CORNERS DENTAL PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LARRY MIZELLE (DENTIST)
(734) 847-6350
Entity
Organization
Contact information
Practice address
7298 JACKMAN RD, TEMPERANCE, MI 48182-1313
(734) 847-6350
Mailing address
7298 JACKMAN RD, TEMPERANCE, MI 48182-1313
(734) 847-6350
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
2901010910
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2901010910
STATE LICENSE
MI
Enumeration date
07/09/2008
Last updated
07/09/2008
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