Provider Demographics
NPI:1134647548
Name:GOULDSBERRY, ADAM (DDS)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:GOULDSBERRY
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 1:373 SEBASTIAN BLVD.
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-4550
Mailing Address - Country:US
Mailing Address - Phone:772-589-7409
Mailing Address - Fax:772-589-0777
Practice Address - Street 1:373 SEBASTIAN BLVD.
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-4550
Practice Address - Country:US
Practice Address - Phone:772-589-7409
Practice Address - Fax:772-589-0777
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101853122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist