Healthcare Provider Details

I. General information

NPI: 1407822661
Provider Name (Legal Business Name): JOHN LEE GOLDSTONE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING 577 STERNBERG AVENUE HQ USADENTAC CREDENTIALS OFFICE
FT. EUSTIS VA
23604-5311
US

IV. Provider business mailing address

BUILDING 577 STERNBERG AVENUE HQ USADENTAC CREDENTIALS OFFICE
FT. EUSTIS VA
23604-5311
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-7944
  • Fax: 757-314-7942
Mailing address:
  • Phone: 757-314-7944
  • Fax: 757-314-7942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401005156
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: