Provider Demographics
NPI:1043202179
Name:BIRNBAUM, MARK B (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:B
Last Name:BIRNBAUM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 OCEAN PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-2060
Mailing Address - Country:US
Mailing Address - Phone:718-998-9114
Mailing Address - Fax:718-998-3727
Practice Address - Street 1:1777 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-2060
Practice Address - Country:US
Practice Address - Phone:718-998-9114
Practice Address - Fax:718-998-3727
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032359122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00399468Medicaid
D7F861Medicare ID - Type Unspecified
NY00399468Medicaid