Provider Demographics
NPI:1073892576
Name:GOODLOE DENTAL, P.A.
Entity Type:Organization
Organization Name:GOODLOE DENTAL, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODLOE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-859-9595
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-0449
Mailing Address - Country:US
Mailing Address - Phone:601-859-9595
Mailing Address - Fax:601-859-9395
Practice Address - Street 1:1207 W PEACE ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-9037
Practice Address - Country:US
Practice Address - Phone:601-859-9595
Practice Address - Fax:601-859-9395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2942-961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660220Medicaid