Provider Demographics
NPI:1730506023
Name:DR. JEFFREY TENENBAUM
Entity type:Organization
Organization Name:DR. JEFFREY TENENBAUM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:TENENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-871-4440
Mailing Address - Street 1:P.O. BOX- 180026
Mailing Address - Street 2:53 CHURCH AVE
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-3040
Mailing Address - Country:US
Mailing Address - Phone:718-871-4440
Mailing Address - Fax:718-633-3198
Practice Address - Street 1:53 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-3040
Practice Address - Country:US
Practice Address - Phone:718-871-4440
Practice Address - Fax:718-633-3198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00526229Medicaid