Provider Demographics
NPI:1952383663
Name:HERTZ, MARC BENJAMIN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:BENJAMIN
Last Name:HERTZ
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 1:1517 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-6339
Mailing Address - Country:US
Mailing Address - Phone:718-998-7654
Mailing Address - Fax:
Practice Address - Street 1:2026 OCEAN AVE
Practice Address - Street 2:SUITE 1K
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-7352
Practice Address - Country:US
Practice Address - Phone:718-998-9999
Practice Address - Fax:718-998-9999
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0466171223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02121520Medicaid