=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073918165
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLIFFORD T. GOODWIN, DDS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2014
-----------------------------------------------------
Last Update Date | 10/31/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12610 PATRICK HENRY DR SUITE G
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23602-9538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-930-3744
-----------------------------------------------------
Fax | 757-930-2726
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12610 PATRICK HENRY DR SUITE G
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23602-9538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-930-3744
-----------------------------------------------------
Fax | 757-930-2726
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. CLIFFORD THOMAS GOODWIN
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 757-930-3744
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 401006165
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------