Provider Demographics
NPI:1568893881
Name:GOLDBERG, IRA (DMD)
Entity Type:Individual
Prefix:DR
First Name:IRA
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 NORTHERN BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-1514
Mailing Address - Country:US
Mailing Address - Phone:516-484-1123
Mailing Address - Fax:516-484-1127
Practice Address - Street 1:1044 NORTHERN BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1514
Practice Address - Country:US
Practice Address - Phone:516-484-1123
Practice Address - Fax:516-484-1127
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0511301223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics