MEDICARE: DR. LISA GOLDBERG DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	2901015879	MI

General Provider Information

NPI Number	:	1043326879
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA GOLDBERG DDS

Provider Business Mailing Address
First Line	:	1814 S ROCHESTER RD
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-3532
Country	:	US
Telephone Number	:	248-608-2626
Fax Number	:	248-608-8149

Provider Business Practice Location Address
First Line	:	1814 S ROCHESTER RD
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-3532
Country	:	US
Telephone Number	:	248-608-2626
Fax Number	:	248-608-8149

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	07/08/2007

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