Provider Demographics
NPI:1346257912
Name:GOODNER, WAYNE KEITH
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:KEITH
Last Name:GOODNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:WAYNE
Other - Middle Name:KEITH
Other - Last Name:GOODNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:1751 W ORANGE GROVE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704
Mailing Address - Country:US
Mailing Address - Phone:520-742-4227
Mailing Address - Fax:520-742-4892
Practice Address - Street 1:1751 W ORANGE GROVE ROAD
Practice Address - Street 2:STE 101
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704
Practice Address - Country:US
Practice Address - Phone:520-742-4227
Practice Address - Fax:520-742-4892
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ07549511Q122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist