Provider Demographics
NPI:1790771608
Name:GOLDMAN, MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
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 1:6903 FRESH POND RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-5264
Mailing Address - Country:US
Mailing Address - Phone:718-821-0997
Mailing Address - Fax:
Practice Address - Street 1:6903 FRESH POND RD
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-5264
Practice Address - Country:US
Practice Address - Phone:718-821-0997
Practice Address - Fax:718-821-6736
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-26
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037211122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00868295Medicaid