Provider Demographics
NPI:1487007696
Name:GOLDBERG, DAVID (DDS, MS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 W MONROE ST
Mailing Address - Street 2:APT 4
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3399
Mailing Address - Country:US
Mailing Address - Phone:218-209-8027
Mailing Address - Fax:
Practice Address - Street 1:332 SKOKIE VALLEY RD
Practice Address - Street 2:SUITE 222
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-4415
Practice Address - Country:US
Practice Address - Phone:847-831-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190295761223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics