Provider Demographics
NPI:1619180957
Name:GOLDBERG, THEODORE I (DMD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:I
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 1:1 LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01721-3018
Mailing Address - Country:US
Mailing Address - Phone:508-309-3147
Mailing Address - Fax:508-473-7234
Practice Address - Street 1:8 ASYLUM ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-2203
Practice Address - Country:US
Practice Address - Phone:508-473-7632
Practice Address - Fax:508-473-7234
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA199361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice