Provider Demographics
NPI:1063427961
Name:COLEMAN-GOODLOE, ERIKA LYNN (DMD)
Entity type:Individual
Prefix:DR
First Name:ERIKA
Middle Name:LYNN
Last Name:COLEMAN-GOODLOE
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:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-0449
Mailing Address - Country:US
Mailing Address - Phone:601-859-9595
Mailing Address - Fax:601-859-9395
Practice Address - Street 1:1207 W PEACE ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-9037
Practice Address - Country:US
Practice Address - Phone:601-859-9595
Practice Address - Fax:601-859-9395
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2942-961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660220Medicaid