Provider Demographics
NPI:1447616966
Name:DESERT VALLEY DENTAL OF TRIC
Entity Type:Organization
Organization Name:DESERT VALLEY DENTAL OF TRIC
Other - Org Name:DESERT VALLEY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:775-971-3971
Mailing Address - Street 1:3665 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-5280
Mailing Address - Country:US
Mailing Address - Phone:775-825-1055
Mailing Address - Fax:775-825-1084
Practice Address - Street 1:420 USA PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:MCCARRAN
Practice Address - State:NV
Practice Address - Zip Code:89434-5612
Practice Address - Country:US
Practice Address - Phone:775-425-1000
Practice Address - Fax:888-279-7992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV48581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty