Provider Demographics
NPI:1124545017
Name:GOODRIDGE, TYLER LANCE MATTHEW (DDS)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:LANCE MATTHEW
Last Name:GOODRIDGE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:TYLER
Other - Middle Name:
Other - Last Name:GOODRIDGE, PLLC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:88 VILCOM CENTER DR STE 190
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-1660
Mailing Address - Country:US
Mailing Address - Phone:919-968-9806
Mailing Address - Fax:919-968-7799
Practice Address - Street 1:88 VILCOM CENTER DR STE 190
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-1660
Practice Address - Country:US
Practice Address - Phone:919-968-9806
Practice Address - Fax:919-968-7799
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC108321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty