Healthcare Provider Details

I. General information

NPI: 1750342275
Provider Name (Legal Business Name): STACY L GOODWILL D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 UNIVERSITY DR S SUITE 3
FARGO ND
58103-4900
US

IV. Provider business mailing address

1630 3RD ST W
WEST FARGO ND
58078-4269
US

V. Phone/Fax

Practice location:
  • Phone: 701-237-3583
  • Fax:
Mailing address:
  • Phone: 701-281-0588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1937
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD11537
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: