Provider Demographics
NPI:1508873167
Name:GOLDMAN, STEPHEN B (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:B
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 N CENTRAL AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203
Mailing Address - Country:US
Mailing Address - Phone:818-240-4555
Mailing Address - Fax:818-240-0419
Practice Address - Street 1:411 N CENTRAL AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203
Practice Address - Country:US
Practice Address - Phone:818-240-4555
Practice Address - Fax:818-240-0419
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA233091223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics