Provider Demographics
NPI:1336121508
Name:HERTZBERG, JACK L (DMD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:L
Last Name:HERTZBERG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492-2578
Mailing Address - Country:US
Mailing Address - Phone:781-444-6650
Mailing Address - Fax:781-444-3607
Practice Address - Street 1:87 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492-2578
Practice Address - Country:US
Practice Address - Phone:781-444-6650
Practice Address - Fax:781-444-3607
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA128671223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics