Healthcare Provider Details

I. General information

NPI: 1790008415
Provider Name (Legal Business Name): MARK ANDREW GOLDBERG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2010
Last Update Date: 04/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1603 S HIAWASSEE RD SUITE 135
ORLANDO FL
32835-6438
US

IV. Provider business mailing address

3400 SW 27TH AVE APT. 1701
MIAMI FL
33133-5307
US

V. Phone/Fax

Practice location:
  • Phone: 407-293-8324
  • Fax: 407-298-7810
Mailing address:
  • Phone: 954-328-3866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number16344
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: