Provider Demographics
NPI:1700285079
Name:GOLDBERG, RACHEL SAMANTHA (DMD)
Entity Type:Individual
Prefix:DR
First Name:RACHEL
Middle Name:SAMANTHA
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 E ROLLINS RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-3808
Mailing Address - Country:US
Mailing Address - Phone:847-546-5550
Mailing Address - Fax:
Practice Address - Street 1:2 E ROLLINS RD
Practice Address - Street 2:SUITE 202
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073-3808
Practice Address - Country:US
Practice Address - Phone:847-546-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029960122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist