=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124195185
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOAN PHYLLIS GOLDSTEIN DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 E WASHINGTON #2902
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-263-2447
-----------------------------------------------------
Fax | 312-263-2158
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 E WASHINTON #2902 COSMETIC DENTAL CENTER OF CHICAGO PC
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-263-2447
-----------------------------------------------------
Fax | 312-263-2158
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 19020341
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------