Provider Demographics
NPI:1801979513
Name:ROSENBERG, IRA NEAL (DDS)
Entity type:Individual
Prefix:DR
First Name:IRA
Middle Name:NEAL
Last Name:ROSENBERG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 GLEN KEITH RD # U
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-3514
Mailing Address - Country:US
Mailing Address - Phone:516-674-1452
Mailing Address - Fax:
Practice Address - Street 1:251 GODWIN AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07432-1882
Practice Address - Country:US
Practice Address - Phone:201-445-2797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038209-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1301802Medicaid