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General NPI Number Information
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NPI Number | 1104539303
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Entity Type | Organization
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Legal Business Name | GOOD LIFE DENTAL
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Dates
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Enumeration Date | 01/03/2023
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Last Update Date | 01/03/2023
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Provider Practice Location Address
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Address Line | 20061 E RITTENHOUSE RD
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City | QUEEN CREEK
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State | AZ
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Zip | 85142-9715
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Country | US
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Telephone | 435-637-2100
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Fax |
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Provider Business Mailing Address
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Address Line | 250 N FAIRGROUNDS RD STE 1
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City | PRICE
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State | UT
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Zip | 84501-4201
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | MARVIN BLANE JACKSON
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Credential | DDS
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Telephone | 435-637-2100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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