Provider Demographics
NPI:1720375223
Name:GOODSON, JEREMY CLARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:CLARK
Last Name:GOODSON
Suffix:
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 1:4320 MCAULEY BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120
Mailing Address - Country:US
Mailing Address - Phone:405-755-4826
Mailing Address - Fax:405-755-9096
Practice Address - Street 1:4320 MCAULEY BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120
Practice Address - Country:US
Practice Address - Phone:405-755-4826
Practice Address - Fax:405-755-9096
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6314122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist