Healthcare Provider Details

I. General information

NPI: 1992957203
Provider Name (Legal Business Name): MICHAEL KEITH GOULSTON M.D., D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2008
Last Update Date: 11/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 DURHAM AVE SUITE 213
SOUTH PLAINFIELD NJ
07080-2548
US

IV. Provider business mailing address

295 DURHAM AVE SUITE 213
SOUTH PLAINFIELD NJ
07080-2548
US

V. Phone/Fax

Practice location:
  • Phone: 908-222-0040
  • Fax: 908-222-0041
Mailing address:
  • Phone: 908-222-0040
  • Fax: 908-222-0041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number050810
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS037951
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number22D102509200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: