Provider Demographics
NPI:1518161710
Name:GOODMAN, MARK H (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:H
Last Name:GOODMAN
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 1:8 NOTTINGHAM DRIVE
Mailing Address - Street 2:
Mailing Address - City:WHEATLEY HTS
Mailing Address - State:NY
Mailing Address - Zip Code:11798
Mailing Address - Country:US
Mailing Address - Phone:631-920-0094
Mailing Address - Fax:
Practice Address - Street 1:133-36 WHITESTONE EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354
Practice Address - Country:US
Practice Address - Phone:718-762-0202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035967122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00628377Medicaid