Provider Demographics
NPI:1538217674
Name:GOODROE, RICHARD NEAL (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:NEAL
Last Name:GOODROE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6185 BUFORD HWY
Mailing Address - Street 2:BUILDING B-102
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-2350
Mailing Address - Country:US
Mailing Address - Phone:770-448-8385
Mailing Address - Fax:770-448-8386
Practice Address - Street 1:6185 BUFORD HWY
Practice Address - Street 2:BUILDING B-102
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-2350
Practice Address - Country:US
Practice Address - Phone:770-448-8385
Practice Address - Fax:770-448-8386
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA71701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4535168-JLOtherGA WITHHOLDING I. D. NUMB