MEDICARE: GOODREAU & RICHARDSON DENTISTRY

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		FL

General Provider Information

NPI Number	:	1669700589
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOODREAU & RICHARDSON DENTISTRY

Provider Business Mailing Address
First Line	:	17350 PANAMA CITY BEACH PKWY
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32413-6039
Country	:	US
Telephone Number	:	850-230-3364
Fax Number	:	850-233-9434

Provider Business Practice Location Address
First Line	:	17350 PANAMA CITY BEACH PKWY
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32413-6039
Country	:	US
Telephone Number	:	850-230-3364
Fax Number	:	850-233-9434

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. SARAH A LARSEN
Credential	:
Telephone Number	:	850-230-3364

Provider Enumeration Date	:	12/04/2009
Last Update Date	:	12/04/2009

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Directions to “GOODREAU & RICHARDSON DENTISTRY ” Practice Location

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