MEDICARE: FINE & GOODMAN 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	122300000X	Dentist	031052	NY

General Provider Information

NPI Number	:	1366454852
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FINE & GOODMAN DDS

Provider Business Mailing Address
First Line	:	12301 82ND RD
Second Line	:
City	:	KEW GARDENS
State	:	NY
Zip	:	11415-1601
Country	:	US
Telephone Number	:	718-261-6303
Fax Number	:	718-261-0307

Provider Business Practice Location Address
First Line	:	12301 82ND RD
Second Line	:
City	:	KEW GARDENS
State	:	NY
Zip	:	11415-1601
Country	:	US
Telephone Number	:	718-261-6303
Fax Number	:	718-261-0307

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHAEL JAY GOODMAN
Credential	:	DDS
Telephone Number	:	718-261-6303

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	08/22/2020

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