Healthcare Provider Details

I. General information

NPI: 1477714236
Provider Name (Legal Business Name): MARVIN A. GERTZBERG, D.D.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 07/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12498 US RTE 9W
WEST COXSACKIE NY
12192
US

IV. Provider business mailing address

12498 STATE RTE 9W
WEST COXSACKIE NY
12192
US

V. Phone/Fax

Practice location:
  • Phone: 518-731-2797
  • Fax: 518-731-9974
Mailing address:
  • Phone: 518-731-2797
  • Fax: 518-731-9974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number036653
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number044897
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number030835
License Number StateNY

VIII. Authorized Official

Name: DR. MARVIN GERTZBERG
Title or Position: OWNER
Credential: DDS
Phone: 518-731-2797