Provider Demographics
NPI:1538353271
Name:IRA GOLDBERG, D.M.D., PLLC
Entity type:Organization
Organization Name:IRA GOLDBERG, D.M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRA
Authorized Official - Middle Name:ELLIOT
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:516-484-1123
Mailing Address - Street 1:1044 NORTHERN BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-1514
Mailing Address - Country:US
Mailing Address - Phone:516-484-1123
Mailing Address - Fax:
Practice Address - Street 1:1044 NORTHERN BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1514
Practice Address - Country:US
Practice Address - Phone:516-484-1123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0511301223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty