MEDICARE: DR. MICHAEL JAY 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	:	1841283108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL JAY GOODMAN DDS

Provider Business Mailing Address
First Line	:	158 SEQUAMS LN W
Second Line	:
City	:	WEST ISLIP
State	:	NY
Zip	:	11795-4549
Country	:	US
Telephone Number	:	631-587-2550
Fax Number	:	631-587-2550

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	07/08/2007

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