Basic Information
| Provider Information | |||||||||
| NPI: | 1750046710 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODWIN | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | MARTINEZ | ||||||||
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| Mailing Information | |||||||||
| Address1: | USA DENTAL HEALTH ACTIVITY | ||||||||
| Address2: | 4301 WILSON ST. | ||||||||
| City: | FORT SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805582795 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 605 RANDOLPH RD | ||||||||
| Address2: | |||||||||
| City: | FORT SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735034535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804425925 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2021 | ||||||||
| LastUpdateDate: | 11/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | DH26493 | 01 | FL | RDH LICENSE | OTHER |