Provider Demographics
NPI:1851495147
Name:GOODIS, MITCHELL ALLEN (DDS)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:ALLEN
Last Name:GOODIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:MITCHELL
Other - Middle Name:ALLEN
Other - Last Name:GOODIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 500
Mailing Address - Street 2:STE 102
Mailing Address - City:DIAMOND SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95619-0500
Mailing Address - Country:US
Mailing Address - Phone:530-344-0290
Mailing Address - Fax:530-344-0291
Practice Address - Street 1:540 PLEASANT VALLEY RD
Practice Address - Street 2:STE 102
Practice Address - City:DIAMOND SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95619-0500
Practice Address - Country:US
Practice Address - Phone:530-344-0290
Practice Address - Fax:530-344-0291
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD430101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice