Provider Demographics
NPI:1275605339
Name:EISENBROCK, MICHAEL L (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:EISENBROCK
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 1:3554 HULMEVILLE RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-4366
Mailing Address - Country:US
Mailing Address - Phone:215-638-9952
Mailing Address - Fax:215-638-1175
Practice Address - Street 1:3554 HULMEVILLE RD
Practice Address - Street 2:SUITE 111
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-4366
Practice Address - Country:US
Practice Address - Phone:215-638-9952
Practice Address - Fax:215-638-1175
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS019531L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA232209954OtherTAX ID
PA103205OtherUNITED CONCORDIA PROVIDER
PADS019531LOtherLICENSE NUMBER