Provider Demographics
NPI:1316940158
Name:BIENENSTOCK, MARC IRWIN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:IRWIN
Last Name:BIENENSTOCK
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 1:1530 PENNSYLVANIA AVE
Mailing Address - Street 2:APT 6H
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11239-2607
Mailing Address - Country:US
Mailing Address - Phone:516-384-8745
Mailing Address - Fax:
Practice Address - Street 1:3809 JUNCTION BLVD
Practice Address - Street 2:FL 2
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-2153
Practice Address - Country:US
Practice Address - Phone:718-639-7100
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0314151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00281907Medicaid