Provider Demographics
NPI:1568755304
Name:GOODING FAMILY DENTAL
Entity Type:Organization
Organization Name:GOODING FAMILY DENTAL
Other - Org Name:GOODING FAMILY AND COSMETIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:NAVARRO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-934-8080
Mailing Address - Street 1:325 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330-1302
Mailing Address - Country:US
Mailing Address - Phone:208-934-8080
Mailing Address - Fax:208-934-9756
Practice Address - Street 1:325 MAIN ST
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330-1302
Practice Address - Country:US
Practice Address - Phone:208-934-8080
Practice Address - Fax:208-934-9756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4355261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental