Provider Demographics
NPI:1558367557
Name:ELLENBOGEN, HERSHEL T (DMD)
Entity Type:Individual
Prefix:DR
First Name:HERSHEL
Middle Name:T
Last Name:ELLENBOGEN
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 1:98 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:WHITINSVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:01588-1416
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:98 CHURCH ST
Practice Address - Street 2:
Practice Address - City:WHITINSVILLE
Practice Address - State:MA
Practice Address - Zip Code:01588-1416
Practice Address - Country:US
Practice Address - Phone:508-234-5073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA191101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX11549OtherBLUE CROSS