Provider Demographics
NPI:1194832436
Name:GOODMAN, A GARY (DDS)
Entity Type:Individual
Prefix:DR
First Name:A
Middle Name:GARY
Last Name:GOODMAN
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 1:1419 FOREST DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403
Mailing Address - Country:US
Mailing Address - Phone:410-263-1919
Mailing Address - Fax:410-267-9163
Practice Address - Street 1:1419 FOREST DR
Practice Address - Street 2:SUITE 207
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21403
Practice Address - Country:US
Practice Address - Phone:410-263-1919
Practice Address - Fax:410-267-9163
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD5906122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist