Provider Demographics
NPI:1801995725
Name:GOODYEAR, GARY LAMAR (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:LAMAR
Last Name:GOODYEAR
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 1:841 KELLER PKWY #203
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248
Mailing Address - Country:US
Mailing Address - Phone:817-741-7000
Mailing Address - Fax:817-745-1100
Practice Address - Street 1:841 KELLER PKWY #203
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248
Practice Address - Country:US
Practice Address - Phone:817-741-7000
Practice Address - Fax:817-745-1100
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX11320OtherSTATE BOARD