Provider Demographics
NPI:1174856751
Name:GOODMAN, AMANDA ALEXIS (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:ALEXIS
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 S ROME AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-3032
Mailing Address - Country:US
Mailing Address - Phone:813-545-9141
Mailing Address - Fax:
Practice Address - Street 1:5111 EHRLICH RD
Practice Address - Street 2:SUITE 130
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-2075
Practice Address - Country:US
Practice Address - Phone:813-964-8833
Practice Address - Fax:813-964-8883
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019026365122300000X
IL0210021241223E0200X
FLDN185671223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist