Provider Demographics
NPI:1316935232
Name:GOODARE-ROSENTHAL, NANCY LEE (DDS, MS)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:LEE
Last Name:GOODARE-ROSENTHAL
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:LEE
Other - Last Name:GOODARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS,MS
Mailing Address - Street 1:155 N HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7364
Mailing Address - Country:US
Mailing Address - Phone:719-588-3146
Mailing Address - Fax:
Practice Address - Street 1:155 N HARBOR DR
Practice Address - Street 2:APT 2409
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-5007
Practice Address - Country:US
Practice Address - Phone:312-996-7546
Practice Address - Fax:312-355-4173
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.030532122300000X
CO8414122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO60501332Medicaid
94984018OtherNEW MEXICO MEDICAID
CO840706945137OtherROCKY MOUNTAIN HEALTH PLA
CO60501332Medicaid
CO60501332Medicaid