Provider Demographics
NPI:1568653186
Name:GOODWIN, JACEY ELIZABETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:JACEY
Middle Name:ELIZABETH
Last Name:GOODWIN
Suffix:
Gender:F
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:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:MILNER
Mailing Address - State:GA
Mailing Address - Zip Code:30257-0520
Mailing Address - Country:US
Mailing Address - Phone:404-617-9695
Mailing Address - Fax:
Practice Address - Street 1:4850 HIGHWAY 19 S
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:GA
Practice Address - Zip Code:30295-3486
Practice Address - Country:US
Practice Address - Phone:404-617-9695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0130951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice