Provider Demographics
NPI:1245833441
Name:BELLROAD DENTISTRY LLC
Entity type:Organization
Organization Name:BELLROAD DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:TERA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOOLSBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-289-2616
Mailing Address - Street 1:34225 N 27TH DR STE 241
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-6091
Mailing Address - Country:US
Mailing Address - Phone:623-289-2616
Mailing Address - Fax:623-289-2015
Practice Address - Street 1:17061 N AVENUE OF THE ARTS STE 101
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378-6996
Practice Address - Country:US
Practice Address - Phone:623-246-5025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental