Provider Demographics
NPI:1215208061
Name:ROTHBERG, IVAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:
Last Name:ROTHBERG
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 1:4 METROTECH CTR
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-8400
Mailing Address - Country:US
Mailing Address - Phone:718-403-0700
Mailing Address - Fax:
Practice Address - Street 1:4 METROTECH CTR
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-8400
Practice Address - Country:US
Practice Address - Phone:718-403-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0261961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice