Healthcare Provider Details

I. General information

NPI: 1508018979
Provider Name (Legal Business Name): MICHAEL J GOODE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2008
Last Update Date: 10/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7905 MALCOLM RD STE#300
CLINTON MD
20735-1734
US

IV. Provider business mailing address

7905 MALCOLM RD STE#300
CLINTON MD
20735-1734
US

V. Phone/Fax

Practice location:
  • Phone: 301-868-5500
  • Fax: 301-877-9393
Mailing address:
  • Phone: 301-868-5500
  • Fax: 301-877-9393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number4912
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: