Provider Demographics
NPI:1205229614
Name:GOODMAN MAA DDS
Entity Type:Organization
Organization Name:GOODMAN MAA DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GOODMAN
Authorized Official - Middle Name:CHESTER
Authorized Official - Last Name:MAA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-826-2525
Mailing Address - Street 1:8654B ON THE MALL # 154B
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-3232
Mailing Address - Country:US
Mailing Address - Phone:714-826-2525
Mailing Address - Fax:
Practice Address - Street 1:8654B ON THE MALL # 154B
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-3232
Practice Address - Country:US
Practice Address - Phone:714-826-2525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44460122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD44460OtherDENTIST