Provider Demographics
NPI:1548268220
Name:GOODMAN, MELVIN DOUGLAS (DR)
Entity type:Individual
Prefix:MR
First Name:MELVIN
Middle Name:DOUGLAS
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11807 SE MCLOUGHLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267
Mailing Address - Country:US
Mailing Address - Phone:503-657-0399
Mailing Address - Fax:503-657-4903
Practice Address - Street 1:11807 SE MCLOUGHLIN BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267
Practice Address - Country:US
Practice Address - Phone:503-657-0399
Practice Address - Fax:503-657-4903
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14625122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist