Provider Demographics
NPI:1871736181
Name:EISENBERG, DAN ELIJAH
Entity type:Individual
Prefix:
First Name:DAN
Middle Name:ELIJAH
Last Name:EISENBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18111 PRINCE PHILIP DR
Mailing Address - Street 2:T-17
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-1513
Mailing Address - Country:US
Mailing Address - Phone:301-774-7887
Mailing Address - Fax:301-774-9221
Practice Address - Street 1:18111 PRINCE PHILIP DR
Practice Address - Street 2:T-17
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1513
Practice Address - Country:US
Practice Address - Phone:301-774-7887
Practice Address - Fax:301-774-9221
Is Sole Proprietor?:No
Enumeration Date:2009-04-16
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13260122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist