Provider Demographics
NPI:1891857223
Name:GOODWINE, BRIAN JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JAMES
Last Name:GOODWINE
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:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:MONTEZUMA CREEK
Mailing Address - State:UT
Mailing Address - Zip Code:84534-0130
Mailing Address - Country:US
Mailing Address - Phone:435-651-3700
Mailing Address - Fax:
Practice Address - Street 1:217 S 100 WEST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:UT
Practice Address - Zip Code:84535
Practice Address - Country:US
Practice Address - Phone:435-587-2528
Practice Address - Fax:435-587-3585
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3601858903122300000X
UT3601859922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
360185Medicare UPIN