MEDICARE: CLIFFORD T. GOODWIN, DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	401006165	VA

General Provider Information

NPI Number	:	1073918165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLIFFORD T. GOODWIN, DDS

Provider Business Mailing Address
First Line	:	12610 PATRICK HENRY DR
Second Line	:	SUITE G
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23602-9538
Country	:	US
Telephone Number	:	757-930-3744
Fax Number	:	757-930-2726

Provider Business Practice Location Address
First Line	:	12610 PATRICK HENRY DR
Second Line	:	SUITE G
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23602-9538
Country	:	US
Telephone Number	:	757-930-3744
Fax Number	:	757-930-2726

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. CLIFFORD THOMAS GOODWIN
Credential	:	D.D.S.
Telephone Number	:	757-930-3744

Provider Enumeration Date	:	10/31/2014
Last Update Date	:	10/31/2014

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