Healthcare Provider Details

I. General information

NPI: 1164567624
Provider Name (Legal Business Name): SCOTT LOUIS GOLDSTEIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1719 N OCEAN AVE STE C
MEDFORD NY
11763-2669
US

IV. Provider business mailing address

1719 N OCEAN AVE STE C
MEDFORD NY
11763-2669
US

V. Phone/Fax

Practice location:
  • Phone: 631-654-4242
  • Fax:
Mailing address:
  • Phone: 631-654-4242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number041152
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: