Provider Demographics
NPI:1497496335
Name:GOODMAN, MICHELE
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3104 HIGHWAY 61 W
Mailing Address - Street 2:
Mailing Address - City:ANDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37705-2101
Mailing Address - Country:US
Mailing Address - Phone:865-806-1667
Mailing Address - Fax:
Practice Address - Street 1:2685 ANDERSONVILLE HWY STE 1
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:TN
Practice Address - Zip Code:37716-6725
Practice Address - Country:US
Practice Address - Phone:865-494-5274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4369124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist