=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316734726
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW CHRISTOPHER GOODWIN DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2025
-----------------------------------------------------
Last Update Date | 04/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 192 WESTERN AVE
-----------------------------------------------------
City | SOUTH PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04106-2428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-405-0004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 FOXCROFT LN
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13066-2503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-530-5710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 14014
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------