MEDICARE: AMY GOODWIN D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	6021	NV

General Provider Information

NPI Number	:	1063674356
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY GOODWIN D.M.D.

Provider Business Mailing Address
First Line	:	9521 BOTTLE CREEK LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-0501
Country	:	US
Telephone Number	:	702-767-2461
Fax Number	:

Provider Business Practice Location Address
First Line	:	6910 S RAINBOW BLVD STE 104
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-3274
Country	:	US
Telephone Number	:	702-362-5437
Fax Number	:	702-631-5437

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2008
Last Update Date	:	07/14/2010

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