Provider Demographics
NPI:1447703657
Name:GOODMAN, GABRIELLE
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3023 EASTLAND BLVD
Mailing Address - Street 2:BUILDING H SUITE #112
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-4106
Mailing Address - Country:US
Mailing Address - Phone:727-797-5151
Mailing Address - Fax:
Practice Address - Street 1:3023 EASTLAND BLVD
Practice Address - Street 2:BUILDING H SUITE #112
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-4106
Practice Address - Country:US
Practice Address - Phone:727-797-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-25
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21928122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist