Healthcare Provider Details

I. General information

NPI: 1497496335
Provider Name (Legal Business Name): MICHELE GOODMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2685 ANDERSONVILLE HWY STE 1
CLINTON TN
37716-6725
US

IV. Provider business mailing address

3104 HIGHWAY 61 W
ANDERSONVILLE TN
37705-2101
US

V. Phone/Fax

Practice location:
  • Phone: 865-494-5274
  • Fax:
Mailing address:
  • Phone: 865-806-1667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number4369
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: