Healthcare Provider Details

I. General information

NPI: 1588070452
Provider Name (Legal Business Name): SETH BENJAMIN GREENBERG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2014
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 BARNUM AVENUE CUTOFF STE 5
STRATFORD CT
06614-5100
US

IV. Provider business mailing address

1400 PELHAM PARKWAY SOUTH JACOBI MEDICAL CENTER
BRONX NY
10461-1119
US

V. Phone/Fax

Practice location:
  • Phone: 203-690-1960
  • Fax:
Mailing address:
  • Phone: 718-918-3230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12418
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number061436
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: