Provider Demographics
NPI:1699835603
Name:GOODMAN, DANIEL TIM JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:TIM
Last Name:GOODMAN
Suffix:JR
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 1:305 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-1625
Mailing Address - Country:US
Mailing Address - Phone:417-326-4113
Mailing Address - Fax:417-326-4115
Practice Address - Street 1:305 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-1625
Practice Address - Country:US
Practice Address - Phone:417-326-4113
Practice Address - Fax:417-326-4115
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050150201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1750791OtherUNITED CONCORDIA