Provider Demographics
NPI:1316963739
Name:SOUTHERN BLVD DENTAL CORP, PA
Entity type:Organization
Organization Name:SOUTHERN BLVD DENTAL CORP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:GOEBBEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-892-8600
Mailing Address - Street 1:2716 SOUTHERN BLVD SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-3741
Mailing Address - Country:US
Mailing Address - Phone:505-892-8600
Mailing Address - Fax:505-892-4215
Practice Address - Street 1:2716 SOUTHERN BLVD SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-3741
Practice Address - Country:US
Practice Address - Phone:505-892-8600
Practice Address - Fax:505-892-4215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD15231223G0001X
NMDD14981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty