Provider Demographics
NPI:1437140191
Name:EISEN, BERNARD M (DDS)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:M
Last Name:EISEN
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 1:21 CENTER STREET
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:NY
Mailing Address - Zip Code:14006
Mailing Address - Country:US
Mailing Address - Phone:716-549-3111
Mailing Address - Fax:716-549-5667
Practice Address - Street 1:21 CENTER STREET
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:NY
Practice Address - Zip Code:14006
Practice Address - Country:US
Practice Address - Phone:716-549-3111
Practice Address - Fax:716-549-5667
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0339421122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00620562Medicaid