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General NPI Number Information
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NPI Number | 1548673320
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Entity Type | Organization
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Legal Business Name | KEN GOODWIN, DMD, PA
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Dates
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Enumeration Date | 06/09/2014
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Last Update Date | 06/09/2014
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Provider Practice Location Address
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Address Line | 403 N THIRD ST
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City | BOONEVILLE
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State | MS
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Zip | 38829-1609
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Country | US
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Telephone | 662-728-8171
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Fax | 662-728-1093
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Provider Business Mailing Address
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Address Line | 403 N THIRD ST
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City | BOONEVILLE
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State | MS
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Zip | 38829-1609
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Country | US
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Telephone | 662-728-8171
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Fax | 662-728-1093
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Authorized Official
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Title or Position | OWNER
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Name | DR. KEN G GOODWIN
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Credential | DMD,PA
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Telephone | 662-728-8171
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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 | 1971-82
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License Number State | MS
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