Provider Demographics
NPI:1407111560
Name:GOLDMAN, MARK ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:GOLDMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2995 CHURCHLAND BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-5642
Mailing Address - Country:US
Mailing Address - Phone:757-638-0900
Mailing Address - Fax:757-638-0944
Practice Address - Street 1:2995 CHURCHLAND BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-5642
Practice Address - Country:US
Practice Address - Phone:757-638-0900
Practice Address - Fax:757-638-0944
Is Sole Proprietor?:No
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010065381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice