Provider Demographics
NPI:1265090443
Name:GOODMAN ROAD DENTAL PLLC
Entity type:Organization
Organization Name:GOODMAN ROAD DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:S
Authorized Official - Last Name:BREAZEAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:901-861-0031
Mailing Address - Street 1:7271 GOODMAN RD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-1906
Mailing Address - Country:US
Mailing Address - Phone:662-895-4737
Mailing Address - Fax:662-893-3239
Practice Address - Street 1:7271 GOODMAN RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1906
Practice Address - Country:US
Practice Address - Phone:662-895-4737
Practice Address - Fax:662-893-3239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty