Healthcare Provider Details

I. General information

NPI: 1457693772
Provider Name (Legal Business Name): SCOTT ROBERTS GOLDBERG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 MAIN ST
MELROSE MA
02176-2711
US

IV. Provider business mailing address

810 MAIN ST
MELROSE MA
02176-2711
US

V. Phone/Fax

Practice location:
  • Phone: 781-662-6228
  • Fax:
Mailing address:
  • Phone: 781-662-6228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN1857513
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: