Provider Demographics
NPI:1720041155
Name:GOODMAN, BEVERLY (DDS)
Entity Type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 BALDWIN AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48340-3412
Mailing Address - Country:US
Mailing Address - Phone:248-338-7333
Mailing Address - Fax:248-338-6793
Practice Address - Street 1:1701 BALDWIN AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48340-3412
Practice Address - Country:US
Practice Address - Phone:248-338-7333
Practice Address - Fax:248-338-6793
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010139671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1966258Medicaid