Provider Demographics
NPI:1245447200
Name:JEFFREY S. MCCOY SUSAN FOWLER GOODWIN D.D.S. INC.
Entity type:Organization
Organization Name:JEFFREY S. MCCOY SUSAN FOWLER GOODWIN D.D.S. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-752-4801
Mailing Address - Street 1:127 PROSPERITY LN
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-3488
Mailing Address - Country:US
Mailing Address - Phone:304-752-4801
Mailing Address - Fax:304-752-4825
Practice Address - Street 1:127 PROSPERITY LN
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3488
Practice Address - Country:US
Practice Address - Phone:304-752-4801
Practice Address - Fax:304-752-4825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006292Medicaid