Provider Demographics
NPI:1346251105
Name:GOODRICH, JOHN EARL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EARL
Last Name:GOODRICH
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:PO BOX 660
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-0660
Mailing Address - Country:US
Mailing Address - Phone:208-587-1111
Mailing Address - Fax:208-587-3921
Practice Address - Street 1:450 W 6TH S
Practice Address - Street 2:BOX 660
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-3483
Practice Address - Country:US
Practice Address - Phone:208-587-3314
Practice Address - Fax:208-587-3921
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD2090122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0026928Medicaid