Provider Demographics
NPI:1043515042
Name:GOODWIN, JAMIE
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3648
Mailing Address - Street 2:
Mailing Address - City:COEUR D' ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816
Mailing Address - Country:US
Mailing Address - Phone:208-292-0697
Mailing Address - Fax:
Practice Address - Street 1:1800 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2570
Practice Address - Country:US
Practice Address - Phone:208-292-0697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist