Healthcare Provider Details

I. General information

NPI: 1649214859
Provider Name (Legal Business Name): MICHAEL P GOLDBERG D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 MOUNT HOPE AVE SUITE 410
BANGOR ME
04401-5691
US

IV. Provider business mailing address

700 MOUNT HOPE AVE SUITE 410
BANGOR ME
04401-5691
US

V. Phone/Fax

Practice location:
  • Phone: 207-941-6700
  • Fax: 207-990-2539
Mailing address:
  • Phone: 207-941-6700
  • Fax: 207-990-2539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number3348
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: