Provider Demographics
NPI:1558408716
Name:GOLDSTEIN, SCOTT
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:GOLDSTEIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3304 BELL BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-1603
Mailing Address - Country:US
Mailing Address - Phone:718-428-8900
Mailing Address - Fax:718-428-1266
Practice Address - Street 1:3304 BELL BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-1603
Practice Address - Country:US
Practice Address - Phone:718-428-8900
Practice Address - Fax:718-428-1266
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0327111223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00464746Medicaid
NYT84733Medicare UPIN
NY50908Medicare ID - Type Unspecified