Provider Demographics
NPI:1790921989
Name:PLEASANT VALLEY DENTAL
Entity Type:Organization
Organization Name:PLEASANT VALLEY DENTAL
Other - Org Name:PLEASANT VALLEY DENTAL, GENERAL DENTAL PRACTICE OF MITCHELL A. GOODIS,
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOODIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:530-344-0290
Mailing Address - Street 1:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:CA
Mailing Address - Zip Code:95623-0568
Mailing Address - Country:US
Mailing Address - Phone:530-622-2862
Mailing Address - Fax:530-622-2072
Practice Address - Street 1:6400 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:CA
Practice Address - Zip Code:95623-4230
Practice Address - Country:US
Practice Address - Phone:530-622-2862
Practice Address - Fax:530-622-2072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-18
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD43010122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1854195417OtherNPI FROM PRIMARY OFFICE AT DIAMOND SPRINGS DENTAL CENTER