Provider Demographics
NPI:1376218909
Name:GOODWINE DENTAL, LLC
Entity Type:Organization
Organization Name:GOODWINE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RONDA
Authorized Official - Middle Name:RICHELLE
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-818-7777
Mailing Address - Street 1:210 E 91ST ST STE A
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-1570
Mailing Address - Country:US
Mailing Address - Phone:317-818-7777
Mailing Address - Fax:317-818-7779
Practice Address - Street 1:210 E 91ST ST STE A
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1570
Practice Address - Country:US
Practice Address - Phone:317-818-7777
Practice Address - Fax:317-818-7779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental