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General NPI Number Information
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NPI Number | 1144279191
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Entity Type | Individual
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Provider Name | SAMUEL GOODLOE III DDS, MD
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Gender | Male
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Dates
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Enumeration Date | 05/08/2006
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Last Update Date | 11/17/2010
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Provider Practice Location Address
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Address Line | 1321 MILLERSPORT HWY SUITE #201
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City | WILLIAMSVILLE
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State | NY
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Zip | 14221-2900
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Country | US
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Telephone | 716-626-0001
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Fax | 716-626-0031
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Provider Business Mailing Address
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Address Line | 1321 MILLERSPORT HWY SUITE #201
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City | WILLIAMSVILLE
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State | NY
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Zip | 14221-2900
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Country | US
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Telephone | 716-626-0001
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Fax | 716-626-0031
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 044038
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 208101
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License Number State | NY
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