Healthcare Provider Details

I. General information

NPI: 1467510636
Provider Name (Legal Business Name): BARRY ORTENBERG GARY P JABLOW CHARLES A BAKER DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 260 MIDDLE COUNTRY ROAD
CORAM NY
11727-0449
US

IV. Provider business mailing address

PO BOX 449
CORAM NY
11727
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 Number
License Number State

VIII. Authorized Official

Name: DR. BARRY ORTENBERG
Title or Position: TREASURER
Credential: DDS
Phone: 631-736-2525