Healthcare Provider Details

I. General information

NPI: 1841283108
Provider Name (Legal Business Name): MICHAEL JAY GOODMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 07/08/2007
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

158 SEQUAMS LN W
WEST ISLIP NY
11795-4549
US

V. Phone/Fax

Practice location:
  • Phone: 718-261-6303
  • Fax: 718-261-0307
Mailing address:
  • Phone: 631-587-2550
  • Fax: 631-587-2550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: