MEDICARE: DR. MICHAEL GOLDMAN D.D.S.

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	122300000X	Dentist	037211	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790771608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL GOLDMAN D.D.S.

Provider Business Mailing Address
First Line	:	6903 FRESH POND RD
Second Line	:
City	:	RIDGEWOOD
State	:	NY
Zip	:	11385-5264
Country	:	US
Telephone Number	:	718-821-0997
Fax Number	:

Provider Business Practice Location Address
First Line	:	6903 FRESH POND RD
Second Line	:
City	:	RIDGEWOOD
State	:	NY
Zip	:	11385-5264
Country	:	US
Telephone Number	:	718-821-0997
Fax Number	:	718-821-6736

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2005
Last Update Date	:	12/29/2015

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