1881670883 NPI number — GLEN R. KREITZBERG D.D.S.,P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881670883 NPI number — GLEN R. KREITZBERG D.D.S.,P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLEN R. KREITZBERG D.D.S.,P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881670883
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
353 VETERANS MEMORIAL HWY
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
COMMACK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11725-4233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-543-5555
Provider Business Mailing Address Fax Number:
631-543-5556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
353 VETERANS MEMORIAL HWY
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
COMMACK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11725-4200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-543-5555
Provider Business Practice Location Address Fax Number:
631-543-5556
Provider Enumeration Date:
12/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KREITZBERG
Authorized Official First Name:
GLEN
Authorized Official Middle Name:
RICHARD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
631-543-5555

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  036804 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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