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General NPI Number Information
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NPI Number | 1083100713
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Entity Type | Individual
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Provider Name | RESID GOLJO
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Gender | Male
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Dates
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Enumeration Date | 07/05/2018
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Last Update Date | 07/05/2018
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Provider Practice Location Address
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Address Line | 677 NE 24TH ST APT 204
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City | MIAMI
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State | FL
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Zip | 33137-4737
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Country | US
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Telephone | 516-250-9832
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Fax |
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Provider Business Mailing Address
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Address Line | 1452 4TH ST
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City | WEST BABYLON
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State | NY
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Zip | 11704-4754
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Country | US
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Telephone | 516-250-9832
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN23648
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License Number State | FL
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