Provider Demographics
NPI:1376892018
Name:DR. LEONARD GOLDMAN, PA
Entity Type:Organization
Organization Name:DR. LEONARD GOLDMAN, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:GOLDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-622-2700
Mailing Address - Street 1:12510 PROSPERITY DR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-1663
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12510 PROSPERITY DR
Practice Address - Street 2:SUITE 250
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-1663
Practice Address - Country:US
Practice Address - Phone:301-622-2700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD8392261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU10092Medicare UPIN
MD1639267172Medicare NSC