MEDICARE: DR. JERRY WAYNE GODKIN DDS MSD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	TX8947	TX

General Provider Information

NPI Number	:	1225253669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY WAYNE GODKIN DDS MSD

Provider Business Mailing Address
First Line	:	17059 STUEBNER AIRLINE RD
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77379-6210
Country	:	US
Telephone Number	:	281-444-3999
Fax Number	:	281-444-8079

Provider Business Practice Location Address
First Line	:	17059 STUEBNER AIRLINE RD
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77379-6210
Country	:	US
Telephone Number	:	281-444-3999
Fax Number	:	281-444-8079

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	10/05/2016

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