Provider Demographics
NPI:1326533605
Name:THE DENTAL CENTER OF QUEEN CREEK, PC
Entity Type:Organization
Organization Name:THE DENTAL CENTER OF QUEEN CREEK, PC
Other - Org Name:GOODMAN DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-807-4000
Mailing Address - Street 1:18610 E RITTENHOUSE RD STE A103
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-4504
Mailing Address - Country:US
Mailing Address - Phone:480-807-4000
Mailing Address - Fax:480-807-4002
Practice Address - Street 1:18610 E RITTENHOUSE RD STE A103
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-4504
Practice Address - Country:US
Practice Address - Phone:480-807-4000
Practice Address - Fax:480-807-4002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD72801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty