Provider Demographics
NPI:1477714236
Name:MARVIN A. GERTZBERG, D.D.S.
Entity Type:Organization
Organization Name:MARVIN A. GERTZBERG, D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GERTZBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:518-731-2797
Mailing Address - Street 1:12498 STATE RTE 9W
Mailing Address - Street 2:
Mailing Address - City:WEST COXSACKIE
Mailing Address - State:NY
Mailing Address - Zip Code:12192
Mailing Address - Country:US
Mailing Address - Phone:518-731-2797
Mailing Address - Fax:518-731-9974
Practice Address - Street 1:12498 US RTE 9W
Practice Address - Street 2:
Practice Address - City:WEST COXSACKIE
Practice Address - State:NY
Practice Address - Zip Code:12192
Practice Address - Country:US
Practice Address - Phone:518-731-2797
Practice Address - Fax:518-731-9974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030835122300000X
NY036653122300000X
NY044897122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00653301Medicaid
NY03016671Medicaid
NY00471898Medicaid
NY02530990Medicaid
NY1538231741Medicaid