Provider Demographics
NPI:1548673320
Name:KEN GOODWIN, DMD, PA
Entity type:Organization
Organization Name:KEN GOODWIN, DMD, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD,PA
Authorized Official - Phone:662-728-8171
Mailing Address - Street 1:403 N THIRD ST
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-1609
Mailing Address - Country:US
Mailing Address - Phone:662-728-8171
Mailing Address - Fax:662-728-1093
Practice Address - Street 1:403 N THIRD ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-1609
Practice Address - Country:US
Practice Address - Phone:662-728-8171
Practice Address - Fax:662-728-1093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1971-821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty