Provider Demographics
NPI:1043275548
Name:GOODMAN, MICHAEL S (D D S)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:D D S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 W GRAYLING LN
Mailing Address - Street 2:
Mailing Address - City:SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06078-1960
Mailing Address - Country:US
Mailing Address - Phone:860-668-6622
Mailing Address - Fax:
Practice Address - Street 1:1315 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-1948
Practice Address - Country:US
Practice Address - Phone:860-450-7471
Practice Address - Fax:860-423-4629
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0039551223P0221X, 1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223D0001XDental ProvidersDentistDental Public Health