Healthcare Provider Details

I. General information

NPI: 1881670883
Provider Name (Legal Business Name): GLEN R. KREITZBERG D.D.S.,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 07/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 VETERANS MEMORIAL HWY SUITE 202
COMMACK NY
11725-4200
US

IV. Provider business mailing address

353 VETERANS MEMORIAL HWY SUITE 202
COMMACK NY
11725-4233
US

V. Phone/Fax

Practice location:
  • Phone: 631-543-5555
  • Fax: 631-543-5556
Mailing address:
  • Phone: 631-543-5555
  • Fax: 631-543-5556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number036804
License Number StateNY

VIII. Authorized Official

Name: DR. GLEN RICHARD KREITZBERG
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 631-543-5555