Healthcare Provider Details

I. General information

NPI: 1861639437
Provider Name (Legal Business Name): MARVIN KERRY ROSENBERG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2009
Last Update Date: 01/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12840 RIVERSIDE DR SUITE 504
STUDIO CITY CA
91607-3327
US

IV. Provider business mailing address

12840 RIVERSIDE DR SUITE 504
STUDIO CITY CA
91607-3327
US

V. Phone/Fax

Practice location:
  • Phone: 818-505-9095
  • Fax: 818-505-1445
Mailing address:
  • Phone: 818-505-9095
  • Fax: 818-505-1445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number27362
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: