Provider Demographics
NPI:1982173746
Name:TDC GOODING PLLC
Entity type:Organization
Organization Name:TDC GOODING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DON
Authorized Official - Middle Name:S
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-324-8861
Mailing Address - Street 1:325 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330
Mailing Address - Country:US
Mailing Address - Phone:208-934-8080
Mailing Address - Fax:208-934-9756
Practice Address - Street 1:325 MAIN STREET
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330
Practice Address - Country:US
Practice Address - Phone:208-934-8080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-21
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty