Provider Demographics
NPI:1750046710
Name:GOODWIN, CHRISTINE MARTINEZ
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARTINEZ
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USA DENTAL HEALTH ACTIVITY
Mailing Address - Street 2:4301 WILSON ST.
Mailing Address - City:FORT SILL
Mailing Address - State:OK
Mailing Address - Zip Code:73503
Mailing Address - Country:US
Mailing Address - Phone:580-558-2795
Mailing Address - Fax:
Practice Address - Street 1:605 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:FORT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503-4535
Practice Address - Country:US
Practice Address - Phone:580-442-5925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDH26493OtherRDH LICENSE