Provider Demographics
NPI:1982683348
Name:GERBER, KENNETH MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MARK
Last Name:GERBER
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 1:5225 NESCONSET HWY
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2053
Mailing Address - Country:US
Mailing Address - Phone:631-331-4200
Mailing Address - Fax:631-331-4248
Practice Address - Street 1:5225 NESCONSET HWY
Practice Address - Street 2:SUITE 6
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2053
Practice Address - Country:US
Practice Address - Phone:631-331-4200
Practice Address - Fax:631-331-4248
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033409122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist