Healthcare Provider Details

I. General information

NPI: 1225442213
Provider Name (Legal Business Name): BUENHOMBRE DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15581 W MACKENZIE DR
GOODYEAR AZ
85395-7779
US

IV. Provider business mailing address

15581 W MACKENZIE DR
GOODYEAR AZ
85395-7779
US

V. Phone/Fax

Practice location:
  • Phone: 520-429-6957
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD008966
License Number StateAZ

VIII. Authorized Official

Name: DR. CALEB GRANT GOODMAN
Title or Position: MEMBER/MANAGER
Credential: DMD
Phone: 520-429-6957