Provider Demographics
NPI:1881670883
Name:GLEN R. KREITZBERG D.D.S.,P.C.
Entity Type:Organization
Organization Name:GLEN R. KREITZBERG D.D.S.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:KREITZBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-543-5555
Mailing Address - Street 1:353 VETERANS MEMORIAL HWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-4233
Mailing Address - Country:US
Mailing Address - Phone:631-543-5555
Mailing Address - Fax:631-543-5556
Practice Address - Street 1:353 VETERANS MEMORIAL HWY
Practice Address - Street 2:SUITE 202
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-4200
Practice Address - Country:US
Practice Address - Phone:631-543-5555
Practice Address - Fax:631-543-5556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-21
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036804261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental