Provider Demographics
NPI:1376738641
Name:GOOD, DALE
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:GOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-5836
Mailing Address - Country:US
Mailing Address - Phone:740-345-7519
Mailing Address - Fax:
Practice Address - Street 1:95 E NORTH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-5836
Practice Address - Country:US
Practice Address - Phone:740-345-7519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
4501382OtherIO WAIVER PROVIDER