1508930751 NPI number — DR. KENNETH EDWARD GOODWIN DDS

Table of content: DR. KENNETH EDWARD GOODWIN DDS (NPI 1508930751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508930751 NPI number — DR. KENNETH EDWARD GOODWIN DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODWIN
Provider First Name:
KENNETH
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508930751
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1540 OLD ALABAMA RD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30076-2136
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-642-8440
Provider Business Mailing Address Fax Number:
770-642-8294

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1540 OLD ALABAMA RD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
ROSWELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30076-2136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-642-8440
Provider Business Practice Location Address Fax Number:
770-642-8294
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN012096 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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