=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811177363
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID P. FISHBERG, DMD, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2007
-----------------------------------------------------
Last Update Date | 11/13/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 590 PARK AVE SUITE 3A
-----------------------------------------------------
City | FREEHOLD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07728-2380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-577-0079
-----------------------------------------------------
Fax | 732-577-7059
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 590 PARK AVE SUITE 3A
-----------------------------------------------------
City | FREEHOLD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07728-2380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-577-0079
-----------------------------------------------------
Fax | 732-577-7059
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DAVID P. FISHBERG
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 732-577-0079
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 22DI01480400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------