Provider Demographics
NPI:1679622922
Name:GOODRICH, JOHN (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:GOODRICH
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4919 DOUGLAS AVE
Mailing Address - Street 2:SUITE 12
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310
Mailing Address - Country:US
Mailing Address - Phone:515-276-3664
Mailing Address - Fax:
Practice Address - Street 1:4919 DOUGLAS AVE
Practice Address - Street 2:SUITE 12
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310
Practice Address - Country:US
Practice Address - Phone:515-276-3664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA64611223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0162909Medicaid
IA162909OtherDELTA DENTAL