Provider Demographics
NPI:1679746069
Name:GOODLOE, JOHN RUSSELL JR (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RUSSELL
Last Name:GOODLOE
Suffix:JR
Gender:M
Credentials:DMD
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Mailing Address - Street 1:1605 HILLCREST RD
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36695-3987
Mailing Address - Country:US
Mailing Address - Phone:251-634-0242
Mailing Address - Fax:251-634-0546
Practice Address - Street 1:1605 HILLCREST RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-3987
Practice Address - Country:US
Practice Address - Phone:251-634-0242
Practice Address - Fax:251-634-0546
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AL26201223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics