Provider Demographics
NPI:1467589648
Name:GOODWIN, JON LEE (DMD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:LEE
Last Name:GOODWIN
Suffix:
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 1:12885 NW CORNELL ROAD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-5813
Mailing Address - Country:US
Mailing Address - Phone:503-646-3200
Mailing Address - Fax:503-646-2397
Practice Address - Street 1:12885 NW CORNELL ROAD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5813
Practice Address - Country:US
Practice Address - Phone:503-646-3200
Practice Address - Fax:503-646-2397
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD61701223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics