Provider Demographics
NPI:1164920377
Name:PHASE 3 LLC
Entity Type:Organization
Organization Name:PHASE 3 LLC
Other - Org Name:PHASE 3 DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOERINGER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:570-690-1718
Mailing Address - Street 1:940 MC INTYRE ST APT B
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-3914
Mailing Address - Country:US
Mailing Address - Phone:570-690-1718
Mailing Address - Fax:
Practice Address - Street 1:940 MC INTYRE ST APT B
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80401-3914
Practice Address - Country:US
Practice Address - Phone:570-690-1718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00202673261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental