Provider Demographics
NPI:1093219164
Name:GOFMAN, REBECCA
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
Last Name:GOFMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 LOCKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-2650
Mailing Address - Country:US
Mailing Address - Phone:203-362-8144
Mailing Address - Fax:
Practice Address - Street 1:4359 KEYSTONE DR STE 100
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-8709
Practice Address - Country:US
Practice Address - Phone:419-893-0221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0258541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice