Provider Demographics
NPI:1518143536
Name:GOLDBERG, JOSE' MARIO (DDS,PA)
Entity Type:Individual
Prefix:DR
First Name:JOSE'
Middle Name:MARIO
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:DDS,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6302 MANATEE AVE W
Mailing Address - Street 2:SUITE A
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-2377
Mailing Address - Country:US
Mailing Address - Phone:941-792-0435
Mailing Address - Fax:941-792-0440
Practice Address - Street 1:6302 MANATEE AVE W
Practice Address - Street 2:SUITE A
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-2377
Practice Address - Country:US
Practice Address - Phone:941-792-0435
Practice Address - Fax:941-792-0440
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN4304122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist