=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164518585
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERNEST JEROME GOODSON DDS, MPA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 950 S MCPHERSON CHURCH RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28303-5351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-483-2633
-----------------------------------------------------
Fax | 910-485-2841
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 950 S MCPHERSON CHURCH RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28303-5351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-483-2633
-----------------------------------------------------
Fax | 910-485-2841
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 104771
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------