Provider Demographics
NPI:1164547105
Name:GOODMAN, CHARLES HARRELL (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:HARRELL
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2835 N SHEFFIELD AVE
Mailing Address - Street 2:SUITE 408
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657
Mailing Address - Country:US
Mailing Address - Phone:773-327-1613
Mailing Address - Fax:773-327-3642
Practice Address - Street 1:2835 N SHEFFIELD AVE
Practice Address - Street 2:SUITE 408
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657
Practice Address - Country:US
Practice Address - Phone:773-327-1613
Practice Address - Fax:773-327-3642
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120094271223P0300X
IL1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics