Healthcare Provider Details

I. General information

NPI: 1043275548
Provider Name (Legal Business Name): MICHAEL S. GOODMAN D. D. S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 MAIN ST
WILLIMANTIC CT
06226-1948
US

IV. Provider business mailing address

131 W GRAYLING LN
SUFFIELD CT
06078-1960
US

V. Phone/Fax

Practice location:
  • Phone: 860-450-7471
  • Fax: 860-423-4629
Mailing address:
  • Phone: 860-668-6622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number003955
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number003955
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: