Provider Demographics
NPI:1770797052
Name:GOODIS, GEORGE THOMAS (DDS)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:THOMAS
Last Name:GOODIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20175 MACK AVENUE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236
Mailing Address - Country:US
Mailing Address - Phone:313-886-4040
Mailing Address - Fax:313-886-4481
Practice Address - Street 1:20175 MACK AVENUE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236
Practice Address - Country:US
Practice Address - Phone:313-886-4040
Practice Address - Fax:313-886-4481
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010085721223E0200X
CA190751223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP06410001Medicare ID - Type Unspecified
T34092Medicare UPIN