Provider Demographics
NPI:1437172715
Name:GOLDSTEIN, GLEN M
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:M
Last Name:GOLDSTEIN
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 1:1243 SUSSEX TPKE
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-2997
Mailing Address - Country:US
Mailing Address - Phone:973-895-7995
Mailing Address - Fax:973-895-2332
Practice Address - Street 1:1243 SUSSEX TPKE
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-2997
Practice Address - Country:US
Practice Address - Phone:973-895-7995
Practice Address - Fax:973-895-2332
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI16078122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist