Provider Demographics
NPI:1679644363
Name:GOLDNER, IVAN N (DMD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:N
Last Name:GOLDNER
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 1:79 W POINT DR
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-5814
Mailing Address - Country:US
Mailing Address - Phone:912-634-9029
Mailing Address - Fax:912-264-1877
Practice Address - Street 1:159 ALTAMA CONNECTOR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-1853
Practice Address - Country:US
Practice Address - Phone:912-264-8408
Practice Address - Fax:912-264-1877
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA75671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice