Provider Demographics
NPI:1568590578
Name:GOODWIN, WINGETT HARLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:WINGETT
Middle Name:HARLEY
Last Name:GOODWIN
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 1:214 E MAIN ST
Mailing Address - Street 2:P.O. BOX 699
Mailing Address - City:SAN AUGUSTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75972-2032
Mailing Address - Country:US
Mailing Address - Phone:936-275-3101
Mailing Address - Fax:936-275-1551
Practice Address - Street 1:214 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SAN AUGUSTINE
Practice Address - State:TX
Practice Address - Zip Code:75972-2032
Practice Address - Country:US
Practice Address - Phone:936-275-3101
Practice Address - Fax:936-275-1551
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX93161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice