Provider Demographics
NPI:1740718386
Name:LINES, GEOFFERY KALVIN (DMD)
Entity type:Individual
Prefix:DR
First Name:GEOFFERY
Middle Name:KALVIN
Last Name:LINES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5640 W HEARN RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4230
Mailing Address - Country:US
Mailing Address - Phone:623-826-8649
Mailing Address - Fax:
Practice Address - Street 1:801 NORTH 2ND AVENUE
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349
Practice Address - Country:US
Practice Address - Phone:928-627-8584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-26
Last Update Date:2017-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0097261223G0001X, 1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health