Provider Demographics
NPI:1588767792
Name:GOODWIN, HARRY H JR (DDS)
Entity type:Individual
Prefix:DR
First Name:HARRY
Middle Name:H
Last Name:GOODWIN
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 RAYMOND DR
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-5806
Mailing Address - Country:US
Mailing Address - Phone:337-463-9289
Mailing Address - Fax:
Practice Address - Street 1:509 BON AMI ST
Practice Address - Street 2:
Practice Address - City:DERIDDER
Practice Address - State:LA
Practice Address - Zip Code:70634-4925
Practice Address - Country:US
Practice Address - Phone:337-463-3272
Practice Address - Fax:337-463-3288
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA24481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1824488Medicaid