Provider Demographics
NPI:1609953389
Name:LORBERBAUM, ROGER (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:LORBERBAUM
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 1:210 CORNELIA STREET
Mailing Address - Street 2:SUITE 402
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901
Mailing Address - Country:US
Mailing Address - Phone:518-563-7990
Mailing Address - Fax:518-563-7992
Practice Address - Street 1:210 CORNELIA STREET
Practice Address - Street 2:SUITE 402
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901
Practice Address - Country:US
Practice Address - Phone:518-563-7990
Practice Address - Fax:518-563-7992
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0305471223S0112X
NY305471223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00374438Medicaid
NY00374438Medicaid
NY30-129BMedicare PIN
NY30129BMedicare PIN