Provider Demographics
NPI:1760741201
Name:GOFF, THEODORE (DDS)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:
Last Name:GOFF
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 1:1636 E 14TH ST STE 123
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1100
Mailing Address - Country:US
Mailing Address - Phone:718-691-5973
Mailing Address - Fax:
Practice Address - Street 1:1636 E 14TH ST STE 123
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1100
Practice Address - Country:US
Practice Address - Phone:718-691-5973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-03
Last Update Date:2023-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY50 049947122300000X
NY0499471223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist