=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871739540
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOODE AND JOHNSON DENTISTRY PARTENRSHIP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2008
-----------------------------------------------------
Last Update Date | 12/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34301 23 MILE RD SUITE 140A
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48047-4432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-725-5500
-----------------------------------------------------
Fax | 586-725-8172
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34301 23 MILE RD SUITE 140A
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48047-4432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-725-5500
-----------------------------------------------------
Fax | 586-725-8172
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL DENTIST
-----------------------------------------------------
Name | DR. RANDALL R GOODE
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 586-725-5500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901019573
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901012324
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------