Provider Demographics
NPI:1336341601
Name:ELLENBOGEN, NORMAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:NORMAN
Middle Name:
Last Name:ELLENBOGEN
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 1:104 HAMPTON STREET
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054
Mailing Address - Country:US
Mailing Address - Phone:518-439-7564
Mailing Address - Fax:
Practice Address - Street 1:17 MAPLE RD
Practice Address - Street 2:
Practice Address - City:VOORHEESVILLE
Practice Address - State:NY
Practice Address - Zip Code:12186-9501
Practice Address - Country:US
Practice Address - Phone:518-765-4616
Practice Address - Fax:518-765-9348
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0274741122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist