Provider Demographics
NPI:1639167646
Name:GOLDSTEIN, LEONARD MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:MARK
Last Name:GOLDSTEIN
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 1:2901 W LEHIGH AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19132-1810
Mailing Address - Country:US
Mailing Address - Phone:215-228-8782
Mailing Address - Fax:215-227-5803
Practice Address - Street 1:2901 W LEHIGH AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132-1810
Practice Address - Country:US
Practice Address - Phone:215-228-8782
Practice Address - Fax:215-227-5803
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS021670L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADS021670LOtherDENTAL LICENSE NUMBER