Healthcare Provider Details

I. General information

NPI: 1821157041
Provider Name (Legal Business Name): CHARLES J GOODIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7520 MONTGOMERY BLVD NE SUITE E1
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

7520 MONTGOMERY BLVD NE SUITE E1
ALBUQUERQUE NM
87109
US

V. Phone/Fax

Practice location:
  • Phone: 505-797-1212
  • Fax: 505-823-1831
Mailing address:
  • Phone: 505-797-1212
  • Fax: 505-823-1831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDD1868
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: