Healthcare Provider Details

I. General information

NPI: 1164438818
Provider Name (Legal Business Name): ROBERT GOOD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

9169 COORS BLVD NW
ALBUQUERQUE NM
87120-3101
US

IV. Provider business mailing address

PO BOX 67830
ALBUQUERQUE NM
87193-7830
US

V. Phone/Fax

Practice location:
  • Phone: 505-346-2306
  • Fax: 505-346-2311
Mailing address:
  • Phone: 505-346-2306
  • Fax: 505-346-2311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2023
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number7096
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12081
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: