Provider Demographics
NPI:1578605036
Name:DR BERNARD M EISEN
Entity Type:Organization
Organization Name:DR BERNARD M EISEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:MEYER
Authorized Official - Last Name:ELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-634-1300
Mailing Address - Street 1:5782 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8219
Mailing Address - Country:US
Mailing Address - Phone:716-634-1300
Mailing Address - Fax:716-634-1378
Practice Address - Street 1:5782 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8219
Practice Address - Country:US
Practice Address - Phone:716-634-1300
Practice Address - Fax:716-634-1378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33942208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00620562Medicaid