Provider Demographics
NPI:1225386758
Name:JC GOODWIN, DMD
Entity Type:Organization
Organization Name:JC GOODWIN, DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:CLINTON
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:928-778-4555
Mailing Address - Street 1:3185 CLEARWATER DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-7119
Mailing Address - Country:US
Mailing Address - Phone:928-778-4555
Mailing Address - Fax:928-778-4560
Practice Address - Street 1:2110 W 24TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8878
Practice Address - Country:US
Practice Address - Phone:855-442-7700
Practice Address - Fax:928-708-9443
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JC GOODWIN, DMD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3540332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment