Provider Demographics
NPI:1558531541
Name:GOLDSTEIN, EVAN (DDS)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:GOLDSTEIN
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 1:100 BROOKLYN AVE
Mailing Address - Street 2:SUITE 1P-R
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-3043
Mailing Address - Country:US
Mailing Address - Phone:516-378-7880
Mailing Address - Fax:
Practice Address - Street 1:100 BROOKLYN AVE
Practice Address - Street 2:SUITE 1P-R
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-3043
Practice Address - Country:US
Practice Address - Phone:516-378-7880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035631-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist