=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659562643
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL K HERZBERG D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2007
-----------------------------------------------------
Last Update Date | 08/06/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18 WILDERNESS LANE
-----------------------------------------------------
City | VALATIE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12184-0806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-758-6359
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 806 18 WILDERNESS LANE
-----------------------------------------------------
City | VALATIE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12184-0806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-758-6359
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 031754
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------