Provider Demographics
NPI:1477600948
Name:GOODMAN, M. DEREK (DDS)
Entity Type:Individual
Prefix:DR
First Name:M.
Middle Name:DEREK
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2937 ESSARY DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-2465
Mailing Address - Country:US
Mailing Address - Phone:865-688-6051
Mailing Address - Fax:865-689-2597
Practice Address - Street 1:2937 ESSARY DR
Practice Address - Street 2:SUITE 1
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37918-2465
Practice Address - Country:US
Practice Address - Phone:865-688-6051
Practice Address - Fax:865-689-2597
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS7276TN1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice