Provider Demographics
NPI:1548561095
Name:AFFORDABLE DENTURES - CLIO, P.C.
Entity Type:Organization
Organization Name:AFFORDABLE DENTURES - CLIO, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:810-686-1277
Mailing Address - Street 1:5105 W VIENNA RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:CLIO
Mailing Address - State:MI
Mailing Address - Zip Code:48420-2811
Mailing Address - Country:US
Mailing Address - Phone:810-686-1277
Mailing Address - Fax:810-686-1582
Practice Address - Street 1:5105 W VIENNA RD
Practice Address - Street 2:SUITE H
Practice Address - City:CLIO
Practice Address - State:MI
Practice Address - Zip Code:48420-2811
Practice Address - Country:US
Practice Address - Phone:810-686-1277
Practice Address - Fax:810-686-1582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-14
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1966258Medicaid