Provider Demographics
NPI:1689297350
Name:GOLDBERG-O'NEIL, EZRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:EZRA
Middle Name:
Last Name:GOLDBERG-O'NEIL
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 1:1100 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209-2308
Mailing Address - Country:US
Mailing Address - Phone:716-242-8200
Mailing Address - Fax:
Practice Address - Street 1:2125 MCCOMAS WAY
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-3986
Practice Address - Country:US
Practice Address - Phone:757-484-8262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-28
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
VA04014178991223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program