Provider Demographics
NPI:1346313798
Name:WEISBERG, MICHAEL K (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K
Last Name:WEISBERG
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 1:1 MARINER WAY
Mailing Address - Street 2:
Mailing Address - City:MONSEY
Mailing Address - State:NY
Mailing Address - Zip Code:10952-1600
Mailing Address - Country:US
Mailing Address - Phone:845-362-7645
Mailing Address - Fax:845-354-1971
Practice Address - Street 1:1 MARINER WAY
Practice Address - Street 2:
Practice Address - City:MONSEY
Practice Address - State:NY
Practice Address - Zip Code:10952-1600
Practice Address - Country:US
Practice Address - Phone:845-362-7645
Practice Address - Fax:845-354-1971
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0499201223X0400X
NJDI 022130001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02351935Medicaid