Provider Demographics
NPI:1679864094
Name:JOHN E. GOODRICH, D.D.S.
Entity Type:Organization
Organization Name:JOHN E. GOODRICH, D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:GOODRICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-587-3314
Mailing Address - Street 1:450 AIRBASE RD
Mailing Address - Street 2:P.O. BOX 660
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-3483
Mailing Address - Country:US
Mailing Address - Phone:208-587-3314
Mailing Address - Fax:208-587-3921
Practice Address - Street 1:450 AIRBASE RD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-3483
Practice Address - Country:US
Practice Address - Phone:208-587-3314
Practice Address - Fax:208-587-3921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-2090122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty