Basic Information
| Provider Information | |||||||||
| NPI: | 1962824102 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDSTEIN | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2211 MERRICK RD | ||||||||
| Address2: | |||||||||
| City: | MERRICK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115664752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163655439 | ||||||||
| FaxNumber: | 5164421019 | ||||||||
| Practice Location | |||||||||
| Address1: | 2211 MERRICK RD | ||||||||
| Address2: | |||||||||
| City: | MERRICK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115664752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163655439 | ||||||||
| FaxNumber: | 5164421019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2014 | ||||||||
| LastUpdateDate: | 07/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1223P0221X | 057339 | NY | Y | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.