Provider Demographics
NPI:1063814812
Name:GOODRICH, JEFFREY A (DDS)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:A
Last Name:GOODRICH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 23RD ST. S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3702
Mailing Address - Country:US
Mailing Address - Phone:701-237-5616
Mailing Address - Fax:701-271-8813
Practice Address - Street 1:1324 23RD ST. S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3702
Practice Address - Country:US
Practice Address - Phone:701-237-5616
Practice Address - Fax:701-271-8813
Is Sole Proprietor?:No
Enumeration Date:2014-09-24
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2318122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist