Provider Demographics
NPI:1619178852
Name:GOLDBERG, AVERY DEAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:AVERY
Middle Name:DEAN
Last Name:GOLDBERG
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 1:2045 LEE RD
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-1836
Mailing Address - Country:US
Mailing Address - Phone:407-629-4444
Mailing Address - Fax:407-629-9078
Practice Address - Street 1:2045 LEE RD
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-1836
Practice Address - Country:US
Practice Address - Phone:407-629-4444
Practice Address - Fax:407-629-9078
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN192021223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery