Provider Demographics
NPI:1154689321
Name:GOODIER, BENJAMIN GAIL (DMD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:GAIL
Last Name:GOODIER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 EAST JACKSON BLVD.
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755
Mailing Address - Country:US
Mailing Address - Phone:573-243-5200
Mailing Address - Fax:573-243-7571
Practice Address - Street 1:3100 EAST JACKSON BLVD.
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755
Practice Address - Country:US
Practice Address - Phone:573-243-5200
Practice Address - Fax:573-243-7571
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO13049122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO400318515Medicaid