Provider Demographics
NPI:1417177197
Name:FASHION PLACE DENTAL PC
Entity Type:Organization
Organization Name:FASHION PLACE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-262-7770
Mailing Address - Street 1:6095 FASHION BLVD
Mailing Address - Street 2:SUITE 3290
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7397
Mailing Address - Country:US
Mailing Address - Phone:801-262-7770
Mailing Address - Fax:801-262-2983
Practice Address - Street 1:6095 FASHION BLVD
Practice Address - Street 2:SUITE 3290
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7397
Practice Address - Country:US
Practice Address - Phone:801-262-7770
Practice Address - Fax:801-262-2983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4737943-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty