Provider Demographics
NPI:1871650945
Name:GOLDBERG, SCOTT IRA (DMD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:IRA
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 BRIDGE ST.
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BILLERICA
Mailing Address - State:MA
Mailing Address - Zip Code:01821
Mailing Address - Country:US
Mailing Address - Phone:978-663-3476
Mailing Address - Fax:978-663-2537
Practice Address - Street 1:17 BRIDGE ST.
Practice Address - Street 2:SUITE 204
Practice Address - City:BILLERICA
Practice Address - State:MA
Practice Address - Zip Code:01821
Practice Address - Country:US
Practice Address - Phone:978-663-3476
Practice Address - Fax:978-663-2537
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA196101223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty