Provider Demographics
NPI:1568643948
Name:L RENEE GOODWIN DDS INC
Entity type:Organization
Organization Name:L RENEE GOODWIN DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:R
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-745-4151
Mailing Address - Street 1:PO BOX 269
Mailing Address - Street 2:100 N. BROADWAY STREET
Mailing Address - City:OAKTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47561-0269
Mailing Address - Country:US
Mailing Address - Phone:812-745-4151
Mailing Address - Fax:812-745-4152
Practice Address - Street 1:100 N. BROADWAY STREET
Practice Address - Street 2:
Practice Address - City:OAKTOWN
Practice Address - State:IN
Practice Address - Zip Code:47561-0269
Practice Address - Country:US
Practice Address - Phone:812-745-4151
Practice Address - Fax:812-745-4152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010355A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200357310Medicaid
IN200435290Medicaid
IN200418020Medicaid