MEDICARE: DAVID GOLDBERG, DDS, MS, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	019029576	IL

General Provider Information

NPI Number	:	1568910784
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVID GOLDBERG, DDS, MS, P.C.

Provider Business Mailing Address
First Line	:	332 SKOKIE VALLEY RD
Second Line	:	SUITE 222
City	:	HIGHLAND PARK
State	:	IL
Zip	:	60035-4415
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	332 SKOKIE VALLEY RD
Second Line	:	SUITE 222
City	:	HIGHLAND PARK
State	:	IL
Zip	:	60035-4415
Country	:	US
Telephone Number	:	847-831-1100
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID GOLDBERG
Credential	:
Telephone Number	:	218-209-8027

Provider Enumeration Date	:	09/16/2016
Last Update Date	:	09/16/2016

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