Provider Demographics
NPI:1326036120
Name:GOLDBERG, KENNETH M (DMD)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:M
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N COLLEGE DRIVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454
Mailing Address - Country:US
Mailing Address - Phone:805-928-7611
Mailing Address - Fax:805-349-8551
Practice Address - Street 1:201 N COLLEGE DRIVE
Practice Address - Street 2:SUITE 202
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454
Practice Address - Country:US
Practice Address - Phone:805-928-7611
Practice Address - Fax:805-349-8551
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI0185681223S0112X
CA594591223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7056508Medicaid
NJU54298Medicare UPIN
NJ7056508Medicaid