Provider Demographics
NPI:1235377623
Name:DIAMOND SPRINGS DENTAL
Entity Type:Organization
Organization Name:DIAMOND SPRINGS DENTAL
Other - Org Name:PLEASANT VALLEY DENTAL, GENERAL DENTAL PRACTICE OF MITCHELL A. GOODIS,
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOODIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:530-344-0290
Mailing Address - Street 1:PO BOX 500
Mailing Address - Street 2:STE. 102
Mailing Address - City:DIAMOND SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95619-0500
Mailing Address - Country:US
Mailing Address - Phone:530-344-0290
Mailing Address - Fax:530-344-0291
Practice Address - Street 1:540 MAIN STREET
Practice Address - Street 2:STE. 102 POST OFFICE BOX 500
Practice Address - City:DIAMOND SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95619-0500
Practice Address - Country:US
Practice Address - Phone:530-344-0290
Practice Address - Fax:530-344-0291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-23
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD43010122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA130082OtherUMITED CONCORDIA