Provider Demographics
NPI:1750473278
Name:WASSERMAN, JERROLD (DDS)
Entity type:Individual
Prefix:DR
First Name:JERROLD
Middle Name:
Last Name:WASSERMAN
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 1:6011 RIVERDALE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10471-1615
Mailing Address - Country:US
Mailing Address - Phone:718-548-6900
Mailing Address - Fax:
Practice Address - Street 1:6011 RIVERDALE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10471-1615
Practice Address - Country:US
Practice Address - Phone:718-548-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027210-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AW1753258OtherDEA #