Provider Demographics
NPI:1194125708
Name:GOODELL, KRISTIN HELLER (DDS)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:HELLER
Last Name:GOODELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:DEE
Other - Last Name:HELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1430 JOHN WESLEY GILBERT DRIVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0001
Mailing Address - Country:US
Mailing Address - Phone:706-721-2371
Mailing Address - Fax:706-721-6778
Practice Address - Street 1:1430 JOHN WESLEY GILBERT DRIVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0001
Practice Address - Country:US
Practice Address - Phone:706-721-2371
Practice Address - Fax:706-721-6778
Is Sole Proprietor?:No
Enumeration Date:2014-09-02
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC99681223G0001X
TX304101223G0001X
KY104821223G0001X
GADN1226001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice