Healthcare Provider Details

I. General information

NPI: 1710388111
Provider Name (Legal Business Name): JACK GOLDBERG SHTEREMBERG DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2014
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S PRESTON ST
LOUISVILLE KY
40202-1701
US

IV. Provider business mailing address

1104 MALLARD CREEK RD
LOUISVILLE KY
40207-5811
US

V. Phone/Fax

Practice location:
  • Phone: 502-852-6928
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number9549
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: