Provider Demographics
NPI:1083100713
Name:GOLJO, RESID
Entity Type:Individual
Prefix:
First Name:RESID
Middle Name:
Last Name:GOLJO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1452 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-4754
Mailing Address - Country:US
Mailing Address - Phone:516-250-9832
Mailing Address - Fax:
Practice Address - Street 1:677 NE 24TH ST APT 204
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-4737
Practice Address - Country:US
Practice Address - Phone:516-250-9832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN23648122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist