Provider Demographics
NPI:1114041266
Name:UNIVERSAL DENTAL GROUP P.L.L.C.
Entity Type:Organization
Organization Name:UNIVERSAL DENTAL GROUP P.L.L.C.
Other - Org Name:UNIVERSAL DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-574-2620
Mailing Address - Street 1:28478 DEQUINDRE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-5605
Mailing Address - Country:US
Mailing Address - Phone:586-574-2620
Mailing Address - Fax:586-574-3015
Practice Address - Street 1:28478 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-5605
Practice Address - Country:US
Practice Address - Phone:586-574-2620
Practice Address - Fax:586-574-3015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI015034122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty