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General NPI Number Information
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NPI Number | 1962604207
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Entity Type | Individual
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Provider Name | WALTER A GOODELL DDS
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Gender | Male
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Dates
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Enumeration Date | 05/31/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 600 E GRAND RIVER AVE SUITE 4A
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City | BRIGHTON
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State | MI
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Zip | 48116-1983
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Country | US
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Telephone | 810-227-2121
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Fax | 810-227-0961
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Provider Business Mailing Address
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Address Line | 4101 N NICHOLSON RD
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City | FOWLERVILLE
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State | MI
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Zip | 48836-8290
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Country | US
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Telephone | 810-227-2121
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Fax | 810-227-0961
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 2901011046
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License Number State | MI
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