Healthcare Provider Details

I. General information

NPI: 1912493677
Provider Name (Legal Business Name): MARK WILLIAM GOULDING D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2018
Last Update Date: 08/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3711 49TH ST N
ST PETERSBURG FL
33710-2153
US

IV. Provider business mailing address

1092 MADISON AVE
ALBANY NY
12208-2248
US

V. Phone/Fax

Practice location:
  • Phone: 727-547-3603
  • Fax: 727-551-4906
Mailing address:
  • Phone: 518-525-1757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN23995
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: