Healthcare Provider Details

I. General information

NPI: 1326113937
Provider Name (Legal Business Name): IRA GOLDMAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 E HALLANDALE BEACH BLVD SUITE 409 TRANS CAPITAL BANK BLDG
HALLANDALE BEACH FL
33009-3765
US

IV. Provider business mailing address

2100 E HALLANDALE BEACH BLVD SUITE 409 TRANS CAPITAL BANK BLDG
HALLANDALE BEACH FL
33009-3765
US

V. Phone/Fax

Practice location:
  • Phone: 954-456-9844
  • Fax: 954-458-3017
Mailing address:
  • Phone: 954-456-9844
  • Fax: 954-458-3017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberFLA5717
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: