Healthcare Provider Details

I. General information

NPI: 1134488778
Provider Name (Legal Business Name): JEFF GOODMAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2012
Last Update Date: 05/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

857 SILVER SPUR RD
ROLLING HILLS ESTATES CA
90274-3803
US

IV. Provider business mailing address

857 SILVER SPUR RD
ROLLING HILLS ESTATES CA
90274-3803
US

V. Phone/Fax

Practice location:
  • Phone: 310-377-0966
  • Fax: 310-377-5224
Mailing address:
  • Phone: 310-377-0966
  • Fax: 310-377-5224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number36369
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: