Provider Demographics
NPI:1710026554
Name:GOLDBERG, MYRON B (DDS)
Entity Type:Individual
Prefix:DR
First Name:MYRON
Middle Name:B
Last Name:GOLDBERG
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 1:2035 MOUNT VERNON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-3235
Mailing Address - Country:US
Mailing Address - Phone:215-236-9845
Mailing Address - Fax:
Practice Address - Street 1:1528 WALNUT ST
Practice Address - Street 2:SUITE 1725
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3604
Practice Address - Country:US
Practice Address - Phone:215-732-0505
Practice Address - Fax:215-732-8744
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADSO20079SL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist