Provider Demographics
NPI:1619350790
Name:GOODMAN, PHILLIP M (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:M
Last Name:GOODMAN
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 1:540 OLD HARBOR CT
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45458-2878
Mailing Address - Country:US
Mailing Address - Phone:937-823-3441
Mailing Address - Fax:
Practice Address - Street 1:105 STATE PARK RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-2914
Practice Address - Country:US
Practice Address - Phone:864-271-1156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC71321223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics