Provider Demographics
NPI:1689661472
Name:GOLDMAN, JEFFREY A (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
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 1:1 THOMPSON SQ
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-3328
Mailing Address - Country:US
Mailing Address - Phone:617-242-0663
Mailing Address - Fax:617-242-8539
Practice Address - Street 1:1 THOMPSON SQ
Practice Address - Street 2:SUITE 203
Practice Address - City:CHARLESTOWN
Practice Address - State:MA
Practice Address - Zip Code:02129-3328
Practice Address - Country:US
Practice Address - Phone:617-242-0663
Practice Address - Fax:617-242-8539
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA144761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0256714Medicaid