MEDICARE: DR. LEONARD MARK GOLDSTEIN 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	1223G0001X	General Practice Dentistry	DS021670L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DS021670L	OTHER	PA	DENTAL LICENSE NUMBER

General Provider Information

NPI Number	:	1639167646
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEONARD MARK GOLDSTEIN DDS

Provider Business Mailing Address
First Line	:	2901 W LEHIGH AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19132-1810
Country	:	US
Telephone Number	:	215-228-8782
Fax Number	:	215-227-5803

Provider Business Practice Location Address
First Line	:	2901 W LEHIGH AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19132-1810
Country	:	US
Telephone Number	:	215-228-8782
Fax Number	:	215-227-5803

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

Provider Enumeration Date	:	10/12/2005
Last Update Date	:	07/10/2007

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