Provider Demographics
NPI:1093801698
Name:GOLDMAN, BRUCE JAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:JAY
Last Name:GOLDMAN
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 1:605 BROADWAY
Mailing Address - Street 2:SUITE #301605 BROADWAY STE 301
Mailing Address - City:SAUGUS
Mailing Address - State:MA
Mailing Address - Zip Code:01906-3200
Mailing Address - Country:US
Mailing Address - Phone:781-233-6844
Mailing Address - Fax:781-233-1765
Practice Address - Street 1:605 BROADWAY
Practice Address - Street 2:SUITE #301605 BROADWAY STE 301
Practice Address - City:SAUGUS
Practice Address - State:MA
Practice Address - Zip Code:01906-3200
Practice Address - Country:US
Practice Address - Phone:781-233-6844
Practice Address - Fax:781-233-1765
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA135101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice