Provider Demographics
NPI:1831390533
Name:GOENAWAN, JULIANI D (DDS)
Entity type:Individual
Prefix:DR
First Name:JULIANI
Middle Name:D
Last Name:GOENAWAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:JULIANI
Other - Middle Name:D
Other - Last Name:WU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2201 E BARNETT RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8259
Mailing Address - Country:US
Mailing Address - Phone:541-776-5271
Mailing Address - Fax:541-776-0814
Practice Address - Street 1:2201 E BARNETT RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8259
Practice Address - Country:US
Practice Address - Phone:541-776-5271
Practice Address - Fax:541-776-0814
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD69241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice