Healthcare Provider Details

I. General information

NPI: 1174557938
Provider Name (Legal Business Name): MARSHALL GOLDBERG D.D.S., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 05/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

837 ZANNA PL
COOS BAY OR
97420-2899
US

IV. Provider business mailing address

PO BOX 1435
COOS BAY OR
97420-0349
US

V. Phone/Fax

Practice location:
  • Phone: 949-610-5513
  • Fax: 541-808-2768
Mailing address:
  • Phone: 949-610-5513
  • Fax: 541-808-2768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number18699
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number18699
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: