=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508396599
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICK GOOCH DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2017
-----------------------------------------------------
Last Update Date | 07/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 VETERANS MEMORIAL HWY STE 200
-----------------------------------------------------
City | ISLANDIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11749-1528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-348-7777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 43 RAYNHAM DR
-----------------------------------------------------
City | SYOSSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11791-3909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-282-4248
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 060033
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------