Provider Demographics
NPI:1568833408
Name:RIVERSIDE SMILES THEODORE I GOLDBERG, DMD PC & ASSOCIATES
Entity Type:Organization
Organization Name:RIVERSIDE SMILES THEODORE I GOLDBERG, DMD PC & ASSOCIATES
Other - Org Name:RIVERSIDE SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:I
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:401-434-4413
Mailing Address - Street 1:250 WAMPANOAG TRAIL SUITE 103
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915
Mailing Address - Country:US
Mailing Address - Phone:401-434-4413
Mailing Address - Fax:401-434-1187
Practice Address - Street 1:250 WAMPANOAG TRAIL SUITE 103
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915
Practice Address - Country:US
Practice Address - Phone:401-434-4413
Practice Address - Fax:401-434-1187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDEN03289122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty