Provider Demographics
NPI:1447600119
Name:GOLDBERG, JASON MICHAEL (DDS)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:GOLDBERG
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 1:8107 E VIA DEL FUTURO
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-3712
Mailing Address - Country:US
Mailing Address - Phone:704-530-8406
Mailing Address - Fax:
Practice Address - Street 1:6520 N 7TH AVE STE 5
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013
Practice Address - Country:US
Practice Address - Phone:602-277-5304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0121251223S0112X
NC119121223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery