Healthcare Provider Details

I. General information

NPI: 1225343858
Provider Name (Legal Business Name): AVRUM GOLDBERG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2010
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3320 RUTGER ST
SAINT LOUIS MO
63104-1122
US

IV. Provider business mailing address

1119 MISSISSIPPI AVE APT. 212
SAINT LOUIS MO
63104-2440
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-8363
  • Fax:
Mailing address:
  • Phone: 314-621-4137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: