Provider Demographics
NPI:1750444162
Name:GOODSON, SUSAN (DMD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:GOODSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 GORDON COMMERCIAL DR # A
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-5740
Mailing Address - Country:US
Mailing Address - Phone:706-845-4035
Mailing Address - Fax:
Practice Address - Street 1:122 GORDON COMMERCIAL DR # A
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-5740
Practice Address - Country:US
Practice Address - Phone:706-845-4035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0091851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice