=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871178962
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | XAVIER GOODE DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2021
-----------------------------------------------------
Last Update Date | 07/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 AVALON DR
-----------------------------------------------------
City | SEAGOVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75159-3034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-287-5513
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1104 JOANNA AVE
-----------------------------------------------------
City | DESOTO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75115-3306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-384-8748
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 37667
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------