1568643948 NPI number — L RENEE GOODWIN DDS INC

Table of content: (NPI 1568643948)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568643948 NPI number — L RENEE GOODWIN DDS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
L RENEE GOODWIN DDS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1568643948
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 269
Provider Second Line Business Mailing Address:
100 N. BROADWAY STREET
Provider Business Mailing Address City Name:
OAKTOWN
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47561-0269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-745-4151
Provider Business Mailing Address Fax Number:
812-745-4152

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 N. BROADWAY STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAKTOWN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47561-0269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-745-4151
Provider Business Practice Location Address Fax Number:
812-745-4152
Provider Enumeration Date:
11/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOODWIN
Authorized Official First Name:
LEAH
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
812-745-4151

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  12010355A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200357310 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200435290 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200418020 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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