Provider Demographics
NPI:1215141353
Name:GOLDEY, JACK WILLIAM (DDS)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:WILLIAM
Last Name:GOLDEY
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 1:736 PRINGLE RD
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-5823
Mailing Address - Country:US
Mailing Address - Phone:386-761-4966
Mailing Address - Fax:386-788-6992
Practice Address - Street 1:3943 S NOVA RD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4910
Practice Address - Country:US
Practice Address - Phone:386-761-9440
Practice Address - Fax:386-788-6992
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL72651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice