Provider Demographics
NPI:1619042587
Name:GOODMAN, JEFFREY ALEXANDER (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALEXANDER
Last Name:GOODMAN
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 1:661 SHUNPIKE RD
Mailing Address - Street 2:SUITE #1
Mailing Address - City:GREEN VILLAGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07935-3022
Mailing Address - Country:US
Mailing Address - Phone:973-377-8811
Mailing Address - Fax:973-377-8847
Practice Address - Street 1:661 SHUNPIKE RD
Practice Address - Street 2:SUITE #1
Practice Address - City:GREEN VILLAGE
Practice Address - State:NJ
Practice Address - Zip Code:07935-3022
Practice Address - Country:US
Practice Address - Phone:973-377-8811
Practice Address - Fax:973-377-8847
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI013485001223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ22DI01348500OtherLICENSE REGISTRATION CERT