Provider Demographics
NPI:1285829598
Name:GOODLETT, JEREMY TYLER (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:TYLER
Last Name:GOODLETT
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 1:630 MANUEL T FREITAS PKWY
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3106
Mailing Address - Country:US
Mailing Address - Phone:415-479-1273
Mailing Address - Fax:
Practice Address - Street 1:630 MANUEL T FREITAS PKWY
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3106
Practice Address - Country:US
Practice Address - Phone:415-479-1273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55078122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist