Healthcare Provider Details

I. General information

NPI: 1508873167
Provider Name (Legal Business Name): STEPHEN B GOLDMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 N CENTRAL AVE SUITE 220
GLENDALE CA
91203
US

IV. Provider business mailing address

411 N CENTRAL AVE SUITE 220
GLENDALE CA
91203
US

V. Phone/Fax

Practice location:
  • Phone: 818-240-4555
  • Fax: 818-240-0419
Mailing address:
  • Phone: 818-240-4555
  • Fax: 818-240-0419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number23309
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: