Provider Demographics
NPI:1902911993
Name:WEINBERG, MARK JEFFREY (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JEFFREY
Last Name:WEINBERG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:387 E MAIN ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8413
Mailing Address - Country:US
Mailing Address - Phone:631-665-5580
Mailing Address - Fax:
Practice Address - Street 1:387 E MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8413
Practice Address - Country:US
Practice Address - Phone:631-665-5580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0422111223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics