Provider Demographics
NPI:1306848429
Name:GOFFREDO, MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:GOFFREDO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21017 SHADY VISTA LN
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-1185
Mailing Address - Country:US
Mailing Address - Phone:561-483-5171
Mailing Address - Fax:
Practice Address - Street 1:23082 SANDALFOOT PLAZA DR
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-6654
Practice Address - Country:US
Practice Address - Phone:561-482-4111
Practice Address - Fax:561-482-4211
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN8005122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist