Provider Demographics
NPI:1962484360
Name:GOLDBERG, JEFFREY ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALAN
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 1:175 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-4532
Mailing Address - Country:US
Mailing Address - Phone:516-921-2880
Mailing Address - Fax:516-921-2889
Practice Address - Street 1:175 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4532
Practice Address - Country:US
Practice Address - Phone:516-921-2880
Practice Address - Fax:516-921-2889
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0415271223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01501266Medicaid
NY01501266Medicaid
NYD5I751Medicare ID - Type Unspecified