Provider Demographics
NPI:1992957203
Name:GOULSTON, MICHAEL KEITH (MD, DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KEITH
Last Name:GOULSTON
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 DURHAM AVE
Mailing Address - Street 2:SUITE 213
Mailing Address - City:SOUTH PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07080-2548
Mailing Address - Country:US
Mailing Address - Phone:908-222-0040
Mailing Address - Fax:908-222-0041
Practice Address - Street 1:295 DURHAM AVE
Practice Address - Street 2:SUITE 213
Practice Address - City:SOUTH PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07080-2548
Practice Address - Country:US
Practice Address - Phone:908-222-0040
Practice Address - Fax:908-222-0041
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-17
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0508101223S0112X
PADS0379511223S0112X
NJ22D1025092001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery