Provider Demographics
NPI:1235275736
Name:GOLDENSOPH, TODD A (DDS)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:A
Last Name:GOLDENSOPH
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 1:1700 MIDLAND RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48638-4339
Mailing Address - Country:US
Mailing Address - Phone:989-792-6629
Mailing Address - Fax:
Practice Address - Street 1:1700 MIDLAND RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48638-4339
Practice Address - Country:US
Practice Address - Phone:989-792-6629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010177001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI124151237Medicaid