Provider Demographics
NPI:1689634404
Name:GOLDMAN, KIM E (DMD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:E
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 LYNDON LN
Mailing Address - Street 2:SUITE 214
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-7351
Mailing Address - Country:US
Mailing Address - Phone:502-582-3750
Mailing Address - Fax:
Practice Address - Street 1:NYU SCHOOL OF DENTISTRY
Practice Address - Street 2:345 EAST 24TH STREET
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4086
Practice Address - Country:US
Practice Address - Phone:212-998-9660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY06323122300000X
CA421521223S0112X
KY63231223S0112X
NY0566811223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64063233Medicaid
NY03658220Medicaid
IN200365950Medicaid