Provider Demographics
NPI:1538741152
Name:GOODWIN, NICOLE (RDH)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:ZUM SPITZBERG 20
Mailing Address - Street 2:
Mailing Address - City:PARSBERG
Mailing Address - State:BAVARIA
Mailing Address - Zip Code:92331
Mailing Address - Country:DE
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ZUM SPITZBERG 20
Practice Address - Street 2:
Practice Address - City:PARSBERG
Practice Address - State:BAVARIA
Practice Address - Zip Code:92331
Practice Address - Country:DE
Practice Address - Phone:307-200-8123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8836215-9920124Q00000X
NY92469-01124Q00000X
TX19548124Q00000X
WY1113124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist