Healthcare Provider Details

I. General information

NPI: 1497115273
Provider Name (Legal Business Name): MATTHEW PHILLIP GOODRICH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2016
Last Update Date: 04/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 MURRAY HILL RD STE G
SOUTHERN PINES NC
28387-6354
US

IV. Provider business mailing address

125 MURRAY HILL RD STE G
SOUTHERN PINES NC
28387-6354
US

V. Phone/Fax

Practice location:
  • Phone: 910-693-1977
  • Fax: 910-693-1877
Mailing address:
  • Phone: 910-693-1977
  • Fax: 910-693-1877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number10153
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. MATTHEW PHILLIP GOODRICH
Title or Position: DENTIST
Credential: D.D.S.
Phone: 910-693-1977