Provider Demographics
NPI:1609304542
Name:GODING, MALLORY ELIZABETH
Entity Type:Individual
Prefix:MS
First Name:MALLORY
Middle Name:ELIZABETH
Last Name:GODING
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 1:76 GARFIELD ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02840-1344
Mailing Address - Country:US
Mailing Address - Phone:717-858-8253
Mailing Address - Fax:
Practice Address - Street 1:1359 MAIN RD
Practice Address - Street 2:
Practice Address - City:TIVERTON
Practice Address - State:RI
Practice Address - Zip Code:02878-4426
Practice Address - Country:US
Practice Address - Phone:401-624-9177
Practice Address - Fax:401-624-9233
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT390200000X
RIDEN03602122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program