Provider Demographics
NPI:1467444117
Name:GOODELL, GARY GERVAIS (DDS, MS, MA)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:GERVAIS
Last Name:GOODELL
Suffix:
Gender:M
Credentials:DDS, MS, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12214 HOLLOW TREE LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6246
Mailing Address - Country:US
Mailing Address - Phone:703-266-9041
Mailing Address - Fax:
Practice Address - Street 1:8901 WISCONSIN AVENUE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-0001
Practice Address - Country:US
Practice Address - Phone:301-295-1831
Practice Address - Fax:301-295-5767
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA64781223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics