Provider Demographics
NPI:1750342275
Name:GOODWILL, STACY L (DDS)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:L
Last Name:GOODWILL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 3RD ST W
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-4269
Mailing Address - Country:US
Mailing Address - Phone:701-281-0588
Mailing Address - Fax:
Practice Address - Street 1:1815 UNIVERSITY DR S
Practice Address - Street 2:SUITE 3
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4900
Practice Address - Country:US
Practice Address - Phone:701-237-3583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND19371223G0001X
MND115371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice