Healthcare Provider Details

I. General information

NPI: 1255347779
Provider Name (Legal Business Name): MICHAEL J DANNENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 08/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 MAIN STREET
HUNTINGTON NY
11743-6951
US

IV. Provider business mailing address

177 MAIN STREET
HUNTINGTON NY
11743-6951
US

V. Phone/Fax

Practice location:
  • Phone: 631-421-4188
  • Fax: 631-421-4197
Mailing address:
  • Phone: 631-421-4188
  • Fax: 631-421-4197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number195567
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: