Provider Demographics
NPI:1609945039
Name:EISENSON, CHARLES B (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:B
Last Name:EISENSON
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 1:1814 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-1732
Mailing Address - Country:US
Mailing Address - Phone:631-273-8111
Mailing Address - Fax:
Practice Address - Street 1:1814 5TH AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-1732
Practice Address - Country:US
Practice Address - Phone:631-273-8111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY50-0351471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00667450Medicaid
NYD2P631Medicare ID - Type Unspecified
NY00667450Medicaid