Provider Demographics
NPI:1982969853
Name:GOODFELLOW, FREDISHA MANNING (DMD)
Entity Type:Individual
Prefix:DR
First Name:FREDISHA
Middle Name:MANNING
Last Name:GOODFELLOW
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 1:900 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-2001
Mailing Address - Country:US
Mailing Address - Phone:870-733-6334
Mailing Address - Fax:870-735-4379
Practice Address - Street 1:900 N 7TH ST
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-2001
Practice Address - Country:US
Practice Address - Phone:870-733-6334
Practice Address - Fax:870-735-4379
Is Sole Proprietor?:No
Enumeration Date:2012-07-06
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3873122300000X
TX28054122300000X
TN9471122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist