Healthcare Provider Details

I. General information

NPI: 1205014792
Provider Name (Legal Business Name): MARC T ADELBERG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 01/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 LAKE AVE S SUITE A
NESCONSET NY
11767-1094
US

IV. Provider business mailing address

62 LAKE AVE S SUITE A
NESCONSET NY
11767-1094
US

V. Phone/Fax

Practice location:
  • Phone: 631-360-7337
  • Fax: 631-360-3815
Mailing address:
  • Phone: 631-360-7337
  • Fax: 631-360-3815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0474231
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: