Active NPI
Clifford Kirby Goodwine, DMD
- Pediatric Dentistry
- Winchester, KY
National Provider Identifier
1679130983
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Dentistry
- License
- 1170
- Practice address
- 11 Canary LN
Winchester, KY 40391-1645 - Phone
- (270) 304-6547
- NPI assigned
- May 22, 2019
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 3
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Dentistry | 1223P0221X | 019.033025 | IL | |
| Student in an Organized Health Care Education/Training Program | 390200000X | KY | ||
| Pediatric Dentistry | 1223P0221X | 1170 | KY | Primary |
Addresses
Primary practice location
11 Canary LN
Winchester, KY 40391-1645
Mailing address
11 Canary LN
Winchester, KY 40391-1645
Phone (270) 304-6547
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 019.033025 | IL | MD | Pediatric Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Dental Professionals of Illinois, P.C. | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
dba Hessel Park Family Dentistry
- General Practice Dentistry
- Champaign, IL
- NPI 1316149867
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1558483200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1683676800000",
"number": "1679130983",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "11 CANARY LN",
"city": "WINCHESTER",
"state": "KY",
"postal_code": "403911645",
"telephone_number": "270-304-6547"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "11 CANARY LN",
"city": "WINCHESTER",
"state": "KY",
"postal_code": "403911645",
"telephone_number": "270-304-6547"
}
],
"practiceLocations": [],
"basic": {
"last_name": "GOODWINE",
"first_name": "CLIFFORD",
"middle_name": "KIRBY",
"name_prefix": "Dr.",
"credential": "DMD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2019-05-22",
"last_updated": "2023-05-10",
"certification_date": "2021-11-06",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "IL",
"license": "019.033025",
"primary": false
},
{
"code": "390200000X",
"taxonomy_group": "",
"desc": "Student in an Organized Health Care Education/Training Program",
"state": "KY",
"license": null,
"primary": false
},
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "KY",
"license": "1170",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Winchester, KY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 10, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.