Provider Demographics
NPI:1770624884
Name:GOODRICH, GLENN RICHARD (DDS,MSD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:RICHARD
Last Name:GOODRICH
Suffix:
Gender:M
Credentials:DDS,MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 PHILOMETHIAN ST
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-2926
Mailing Address - Country:US
Mailing Address - Phone:440-247-9444
Mailing Address - Fax:
Practice Address - Street 1:54 PHILOMETHIAN ST
Practice Address - Street 2:
Practice Address - City:CHAGRIN FALLS
Practice Address - State:OH
Practice Address - Zip Code:44022-2926
Practice Address - Country:US
Practice Address - Phone:440-247-9444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0180961223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics