Healthcare Provider Details

I. General information

NPI: 1205922697
Provider Name (Legal Business Name): CARY ELLIS GOLDSTEIN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 E ANDREWS DR NW SUITE A
ATLANTA GA
30305-1315
US

IV. Provider business mailing address

134 E ANDREWS DR NW STE A
ATLANTA GA
30305-1315
US

V. Phone/Fax

Practice location:
  • Phone: 404-869-7711
  • Fax: 404-869-7755
Mailing address:
  • Phone: 404-869-7711
  • Fax: 404-869-7755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number010028
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: