Healthcare Provider Details

I. General information

NPI: 1376892018
Provider Name (Legal Business Name): DR. LEONARD GOLDMAN, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2012
Last Update Date: 09/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12510 PROSPERITY DR SUITE 250
SILVER SPRING MD
20904-1663
US

IV. Provider business mailing address

12510 PROSPERITY DR SUITE 250
SILVER SPRING MD
20904-1663
US

V. Phone/Fax

Practice location:
  • Phone: 301-622-2700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number8392
License Number StateMD

VIII. Authorized Official

Name: DR. LEONARD JAY GOLDMAN
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 301-622-2700