=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184107880
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL M. GOODING DMD L.T.D
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2018
-----------------------------------------------------
Last Update Date | 02/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1422 WARWICK AVE
-----------------------------------------------------
City | WARWICK
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02888-5026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-463-7678
-----------------------------------------------------
Fax | 401-463-3897
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1422 WARWICK AVE
-----------------------------------------------------
City | WARWICK
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02888-5026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-463-7678
-----------------------------------------------------
Fax | 401-463-3897
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. ELISSA MARIE JUBINVILLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 401-463-7678
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------