Healthcare Provider Details

I. General information

NPI: 1114098076
Provider Name (Legal Business Name): BARRY ORTENBERG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248-260 MIDDLE COUNTRY ROAD SUITE 22
CORAM NY
11727-0449
US

IV. Provider business mailing address

PO BOX 449
CORAM NY
11727-0449
US

V. Phone/Fax

Practice location:
  • Phone: 631-736-2525
  • Fax: 631-736-6825
Mailing address:
  • Phone: 631-736-2525
  • Fax: 631-736-6825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number031591
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: