Provider Demographics
NPI:1104983501
Name:GOOLSBY, JOHN B (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:GOOLSBY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1429 PINE ISLAND VW
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3839
Mailing Address - Country:US
Mailing Address - Phone:843-856-2245
Mailing Address - Fax:
Practice Address - Street 1:1064 GARDNER RD
Practice Address - Street 2:SUITE 104
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-5768
Practice Address - Country:US
Practice Address - Phone:843-571-5656
Practice Address - Fax:843-571-2422
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice