Healthcare Provider Details

I. General information

NPI: 1457579062
Provider Name (Legal Business Name): GOODYEAR ENDODONTICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2007
Last Update Date: 10/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1646 N LITCHFIELD RD #260
GOODYEAR AZ
85395-1387
US

IV. Provider business mailing address

1646 N LITCHFIELD RD #260
GOODYEAR AZ
85395-1387
US

V. Phone/Fax

Practice location:
  • Phone: 623-535-7899
  • Fax:
Mailing address:
  • Phone: 623-535-7899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number3266
License Number StateAZ

VIII. Authorized Official

Name: ROBERT STEPHEN KANE
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 623-535-7899