MEDICARE: GOODE FAMILY DENTAL LLC

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	1223G0001X	General Practice Dentistry	D9436	OR

General Provider Information

NPI Number	:	1154694776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOODE FAMILY DENTAL LLC

Provider Business Mailing Address
First Line	:	7417 CRATER LAKE HWY
Second Line	:
City	:	WHITE CITY
State	:	OR
Zip	:	97503-1662
Country	:	US
Telephone Number	:	541-830-0043
Fax Number	:

Provider Business Practice Location Address
First Line	:	7417 CRATER LAKE HWY
Second Line	:
City	:	WHITE CITY
State	:	OR
Zip	:	97503-1662
Country	:	US
Telephone Number	:	541-830-0043
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHAEL GOODE
Credential	:	DDS
Telephone Number	:	541-830-0043

Provider Enumeration Date	:	02/13/2012
Last Update Date	:	02/13/2012

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