Provider Demographics
NPI:1982759049
Name:ROSENBERG, SIMON WALTER (DMD)
Entity Type:Individual
Prefix:DR
First Name:SIMON
Middle Name:WALTER
Last Name:ROSENBERG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:399 E 72ND ST
Mailing Address - Street 2:SUITE #1A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4648
Mailing Address - Country:US
Mailing Address - Phone:212-988-8822
Mailing Address - Fax:212-988-8858
Practice Address - Street 1:399 E 72ND ST
Practice Address - Street 2:SUITE #1A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4648
Practice Address - Country:US
Practice Address - Phone:212-988-8822
Practice Address - Fax:212-988-8858
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335451223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT81195Medicare UPIN