Provider Demographics
NPI:1821303538
Name:GOODMAN, BROCK AARON (DDS)
Entity Type:Individual
Prefix:DR
First Name:BROCK
Middle Name:AARON
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3722 LAS VEGAS BLVD S
Mailing Address - Street 2:2104E
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89158-4301
Mailing Address - Country:US
Mailing Address - Phone:408-621-5779
Mailing Address - Fax:
Practice Address - Street 1:702 C ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-5308
Practice Address - Country:US
Practice Address - Phone:408-621-5779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA599011223X0400X
NV60231223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics