Provider Demographics
NPI:1750307898
Name:EBSTEIN, JERRY MICHEAL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:MICHEAL
Last Name:EBSTEIN
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 1:137 DRISCOLL AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-6005
Mailing Address - Country:US
Mailing Address - Phone:516-766-0517
Mailing Address - Fax:
Practice Address - Street 1:137 DRISCOLL AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-6005
Practice Address - Country:US
Practice Address - Phone:516-766-0517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0296741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice