Provider Demographics
NPI:1841219276
Name:GOODWIN, CLIFFORD T (DDS)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:T
Last Name:GOODWIN
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 1:12610 PATRICK HENRY DR
Mailing Address - Street 2:STE G
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-9538
Mailing Address - Country:US
Mailing Address - Phone:757-930-3355
Mailing Address - Fax:757-930-2726
Practice Address - Street 1:12515 WARWICK BLVD STE 203
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2964
Practice Address - Country:US
Practice Address - Phone:757-930-3744
Practice Address - Fax:757-930-2726
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA6165122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist