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General NPI Number Information
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NPI Number | 1124284658
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Entity Type | Organization
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Legal Business Name | DANIEL T. GOODMAN DDS LLC
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Dates
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Enumeration Date | 08/04/2008
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Last Update Date | 08/04/2008
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Provider Practice Location Address
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Address Line | 305 E BROADWAY ST
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City | BOLIVAR
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State | MO
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Zip | 65613-1625
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Country | US
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Telephone | 417-326-4113
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Fax | 417-326-4115
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Provider Business Mailing Address
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Address Line | 305 E BROADWAY ST
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City | BOLIVAR
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State | MO
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Zip | 65613-1625
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Country | US
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Telephone | 417-326-4113
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Fax | 417-326-4115
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. DANIEL T GOODMAN
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Credential | DDS
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Telephone | 417-326-4113
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2005015020
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License Number State | MO
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