Provider Demographics
NPI:1376012724
Name:GOOLSBY, JOHN MELVIN JR (DMD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MELVIN
Last Name:GOOLSBY
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 HIGHWAY 80 EAST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056
Mailing Address - Country:US
Mailing Address - Phone:601-925-4044
Mailing Address - Fax:601-925-4240
Practice Address - Street 1:457 HIGHWAY 80 EAST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056
Practice Address - Country:US
Practice Address - Phone:601-925-4044
Practice Address - Fax:601-925-4240
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3232-021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice