Provider Demographics
NPI:1912493677
Name:GOULDING, MARK WILLIAM (DMD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:GOULDING
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 1:1092 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-2248
Mailing Address - Country:US
Mailing Address - Phone:518-525-1757
Mailing Address - Fax:
Practice Address - Street 1:3711 49TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-2153
Practice Address - Country:US
Practice Address - Phone:727-547-3603
Practice Address - Fax:727-551-4906
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN239951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program