Healthcare Provider Details

I. General information

NPI: 1952784902
Provider Name (Legal Business Name): DUSTIN VINAL GOODWIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 E 1400 S
GARLAND UT
84312-9316
US

IV. Provider business mailing address

75 E 1400 S PO BOX 99
GARLAND UT
84312-9316
US

V. Phone/Fax

Practice location:
  • Phone: 435-257-7016
  • Fax: 435-257-4590
Mailing address:
  • Phone: 435-257-7016
  • Fax: 435-257-4590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6370849
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: