Provider Demographics
NPI:1851394894
Name:GOODMAN, KENNETH A (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:GOODMAN
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 1:5925 VENTURE PARK
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-1859
Mailing Address - Country:US
Mailing Address - Phone:269-353-3700
Mailing Address - Fax:269-353-3701
Practice Address - Street 1:5925 VENTURE PARK
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-1859
Practice Address - Country:US
Practice Address - Phone:269-353-3700
Practice Address - Fax:269-353-3701
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2007-07-08
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-20
Provider Licenses
StateLicense IDTaxonomies
MI118071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice