Provider Demographics
NPI:1477734598
Name:GOODWIN, MICHAEL D (DDS, MS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11045 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-7473
Mailing Address - Country:US
Mailing Address - Phone:219-662-1200
Mailing Address - Fax:219-662-1888
Practice Address - Street 1:11045 BROADWAY
Practice Address - Street 2:SUITE B
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7474
Practice Address - Country:US
Practice Address - Phone:219-662-1200
Practice Address - Fax:219-662-1888
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN75521223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics