Provider Demographics
NPI:1437244407
Name:MARK A. GOLDMAN, DDS, PC
Entity Type:Organization
Organization Name:MARK A. GOLDMAN, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOLDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:757-638-0900
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA6538261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental