Provider Demographics
NPI:1326677204
Name:GOLUB, BENJAMIN DYLAN
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:DYLAN
Last Name:GOLUB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 BLUEBERRY DRIVE
Mailing Address - Street 2:
Mailing Address - City:WOODCLIFF LAKE
Mailing Address - State:NJ
Mailing Address - Zip Code:07677
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 BLUEBERRY DR
Practice Address - Street 2:
Practice Address - City:WOODCLIFF LAKE
Practice Address - State:NJ
Practice Address - Zip Code:07677-8106
Practice Address - Country:US
Practice Address - Phone:201-543-9741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DIO28941011223G0001X
NJ22DIO2894100122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice