Provider Demographics
NPI:1720189319
Name:GOODWIN JR, ROBERT A (DMD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:GOODWIN JR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216B JACK MARTIN BLVD
Mailing Address - Street 2:OCEAN MED PK STE D4
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-7771
Mailing Address - Country:US
Mailing Address - Phone:732-458-8100
Mailing Address - Fax:732-458-8103
Practice Address - Street 1:216B JACK MARTIN BLVD
Practice Address - Street 2:OCEAN MED PK STE D4
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-7771
Practice Address - Country:US
Practice Address - Phone:732-458-8100
Practice Address - Fax:732-458-8103
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI014015001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ024038Medicare PIN