Provider Demographics
NPI:1639267172
Name:GOLDMAN, LEONARD JAY (DDS)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:JAY
Last Name:GOLDMAN
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 1:12510 PROSPERITY DRIVE
Mailing Address - Street 2:SUITE #250
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904
Mailing Address - Country:US
Mailing Address - Phone:301-622-2700
Mailing Address - Fax:301-622-2703
Practice Address - Street 1:12510 PROSPERITY DRIVE
Practice Address - Street 2:SUITE #250
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904
Practice Address - Country:US
Practice Address - Phone:301-622-2700
Practice Address - Fax:301-622-2703
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD83921223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD523374Medicare ID - Type Unspecified
MDU10092Medicare UPIN