Provider Demographics
NPI:1164595237
Name:GOLDBERG, PERRY JAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:PERRY
Middle Name:JAY
Last Name:GOLDBERG
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 1:175 JERICHO TPKE
Mailing Address - Street 2:SUITE 115A
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-4595
Mailing Address - Country:US
Mailing Address - Phone:516-364-2550
Mailing Address - Fax:516-364-2551
Practice Address - Street 1:175 JERICHO TPKE
Practice Address - Street 2:SUITE 115A
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4595
Practice Address - Country:US
Practice Address - Phone:516-364-2550
Practice Address - Fax:516-364-2551
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0275231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice