Healthcare Provider Details

I. General information

NPI: 1992709786
Provider Name (Legal Business Name): REGINALD ALVIN GOODMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

175 LEE ST
LUMBERTON TX
77657-7577
US

IV. Provider business mailing address

160 WINDSOR CIR
LUMBERTON TX
77657-7166
US

V. Phone/Fax

Practice location:
  • Phone: 409-755-6565
  • Fax:
Mailing address:
  • Phone: 409-755-6565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10921
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: