Provider Demographics
NPI:1366551152
Name:GOODIN, KELLY M (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:M
Last Name:GOODIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 2ND AVE
Mailing Address - Street 2:#106
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-6247
Mailing Address - Country:US
Mailing Address - Phone:760-636-2866
Mailing Address - Fax:
Practice Address - Street 1:2701 2ND AVE
Practice Address - Street 2:#106
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-6247
Practice Address - Country:US
Practice Address - Phone:760-636-2866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADSO29669L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist