MEDICARE: DR. DONALD LEE GOUDY JR. DDS, INC.

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	41013	CA

General Provider Information

NPI Number	:	1649360603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DONALD LEE GOUDY JR. DDS, INC.

Provider Business Mailing Address
First Line	:	1050 S BASCOM AVE
Second Line	:	SUITE 200
City	:	SAN JOSE
State	:	CA
Zip	:	95128-3549
Country	:	US
Telephone Number	:	408-995-0400
Fax Number	:	408-995-0415

Provider Business Practice Location Address
First Line	:	1050 S BASCOM AVE
Second Line	:	SUITE 200
City	:	SAN JOSE
State	:	CA
Zip	:	95128-3549
Country	:	US
Telephone Number	:	408-995-0400
Fax Number	:	408-995-0415

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

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	07/08/2007

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