Healthcare Provider Details

I. General information

NPI: 1366454852
Provider Name (Legal Business Name): FINE & GOODMAN DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12301 82ND RD
KEW GARDENS NY
11415-1601
US

IV. Provider business mailing address

12301 82ND RD
KEW GARDENS NY
11415-1601
US

V. Phone/Fax

Practice location:
  • Phone: 718-261-6303
  • Fax: 718-261-0307
Mailing address:
  • Phone: 718-261-6303
  • Fax: 718-261-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number031052
License Number StateNY

VIII. Authorized Official

Name: DR. MICHAEL JAY GOODMAN
Title or Position: OWNER
Credential: DDS
Phone: 718-261-6303