Provider Demographics
NPI:1487710299
Name:GOLDMAN, BRUCE ALAN (DDS)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALAN
Last Name:GOLDMAN
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 1:265 E STREET
Mailing Address - Street 2:SUITE E
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910
Mailing Address - Country:US
Mailing Address - Phone:619-427-9440
Mailing Address - Fax:619-427-4756
Practice Address - Street 1:265 E ST
Practice Address - Street 2:SUITE E
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-2930
Practice Address - Country:US
Practice Address - Phone:619-427-9440
Practice Address - Fax:619-427-4756
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA236121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA502057Medicare ID - Type Unspecified