Provider Demographics
NPI:1871514430
Name:KIRSCHBAUM, MITCHELL MARK (DDS)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:MARK
Last Name:KIRSCHBAUM
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 1:223 W MAIN ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:BOONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07005-1166
Mailing Address - Country:US
Mailing Address - Phone:973-334-8228
Mailing Address - Fax:973-822-3036
Practice Address - Street 1:223 W MAIN ST
Practice Address - Street 2:SUITE 4
Practice Address - City:BOONTON
Practice Address - State:NJ
Practice Address - Zip Code:07005-1166
Practice Address - Country:US
Practice Address - Phone:973-334-8228
Practice Address - Fax:973-822-3036
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ99381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice