Provider Demographics
NPI:1831333228
Name:GOODREAU, WANDA FRANCES (DMD)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:FRANCES
Last Name:GOODREAU
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 SHADY OAKS LN
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-3098
Mailing Address - Country:US
Mailing Address - Phone:850-819-3636
Mailing Address - Fax:
Practice Address - Street 1:1415 GOVERNORS SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-3049
Practice Address - Country:US
Practice Address - Phone:850-583-5748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00138751223E0200X
FLDN138751223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty