MEDICARE: DR. GLENN CHARLES GOODRICH M.S

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	11599	OH

General Provider Information

NPI Number	:	1578718672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLENN CHARLES GOODRICH M.S

Provider Business Mailing Address
First Line	:	34501 AURORA RD STE 305
Second Line	:
City	:	SOLON
State	:	OH
Zip	:	44139-3831
Country	:	US
Telephone Number	:	440-248-4825
Fax Number	:	440-248-5489

Provider Business Practice Location Address
First Line	:	34501 AURORA RD STE 305
Second Line	:
City	:	SOLON
State	:	OH
Zip	:	44139-3831
Country	:	US
Telephone Number	:	440-248-4825
Fax Number	:	440-248-5489

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2008
Last Update Date	:	11/18/2008

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