Provider Demographics
NPI:1578811758
Name:GOODELL, KURT (DDS)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:
Last Name:GOODELL
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 1:228 E HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-6011
Mailing Address - Country:US
Mailing Address - Phone:706-787-5531
Mailing Address - Fax:
Practice Address - Street 1:228 E HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-6011
Practice Address - Country:US
Practice Address - Phone:706-787-5531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS616901223E0200X
TX282361223G0001X, 1223E0200X
GADN1229281223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADN122928OtherDENTAL LICENSE
KY10383OtherDENTAL LICENSE
KS61690OtherDENTAL LICENSE
TX28236OtherDENTAL LISCENSE