Provider Demographics
NPI:1164443297
Name:ROYTBERG, SIMON (DDS)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:ROYTBERG
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 1:375 W ROUTE 59
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10977-5360
Mailing Address - Country:US
Mailing Address - Phone:845-356-3353
Mailing Address - Fax:845-356-3376
Practice Address - Street 1:375 W ROUTE 59
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10977-5360
Practice Address - Country:US
Practice Address - Phone:845-356-3353
Practice Address - Fax:845-356-3376
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0506771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02521391Medicaid