Provider Demographics
NPI:1073660510
Name:GOLBERG, LEONID (DDS)
Entity Type:Individual
Prefix:
First Name:LEONID
Middle Name:
Last Name:GOLBERG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 AVENUE O
Mailing Address - Street 2:#1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-6712
Mailing Address - Country:US
Mailing Address - Phone:718-375-3572
Mailing Address - Fax:718-375-3572
Practice Address - Street 1:1608 AVENUE O
Practice Address - Street 2:#1
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-6712
Practice Address - Country:US
Practice Address - Phone:718-375-3572
Practice Address - Fax:718-375-3572
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044834122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01453492Medicaid
NY01453492Medicaid