Provider Demographics
NPI:1770790149
Name:GOSHEN FAMILY & COSMETIC DENTISTRY, INC
Entity type:Organization
Organization Name:GOSHEN FAMILY & COSMETIC DENTISTRY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DEAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-534-5528
Mailing Address - Street 1:1625 SUNNYFIELD DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-9264
Mailing Address - Country:US
Mailing Address - Phone:574-534-5582
Mailing Address - Fax:574-534-8146
Practice Address - Street 1:1625 SUNNYFIELD DR
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-9264
Practice Address - Country:US
Practice Address - Phone:574-534-5582
Practice Address - Fax:574-534-8146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120101431223G0001X
IN120101081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty