Provider Demographics
NPI:1679679435
Name:DUSTIN V. GOODWIN D.D.S. P.C
Entity Type:Organization
Organization Name:DUSTIN V. GOODWIN D.D.S. P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:VINAL
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-257-7016
Mailing Address - Street 1:75 E 1400 S
Mailing Address - Street 2:PO BOX 99
Mailing Address - City:GARLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84312-9316
Mailing Address - Country:US
Mailing Address - Phone:435-257-7016
Mailing Address - Fax:435-257-4590
Practice Address - Street 1:75 E 1400 S
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:UT
Practice Address - Zip Code:84312-9316
Practice Address - Country:US
Practice Address - Phone:435-257-7016
Practice Address - Fax:435-257-4590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-35321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806174600Medicaid
1319810OtherUNITED CONCORDIA/TRICARE
6H429OtherBLUE CROSS