Provider Demographics
NPI:1124339122
Name:GOODE, MICHAEL GARRETT (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GARRETT
Last Name:GOODE
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 1:7417 CRATER LAKE HWY
Mailing Address - Street 2:
Mailing Address - City:WHITE CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97503-1662
Mailing Address - Country:US
Mailing Address - Phone:541-830-0043
Mailing Address - Fax:
Practice Address - Street 1:7417 CRATER LAKE HWY
Practice Address - Street 2:
Practice Address - City:WHITE CITY
Practice Address - State:OR
Practice Address - Zip Code:97503-1662
Practice Address - Country:US
Practice Address - Phone:541-830-0043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-24
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD94361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice