MEDICARE: EXCELLENCE IN DENTISTRY PA

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	1223G0001X	General Practice Dentistry	D3983	ID
2	1223G0001X	General Practice Dentistry	D1637	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881602266
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXCELLENCE IN DENTISTRY PA

Provider Business Mailing Address
First Line	:	2515 CHANNING WAY
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7516
Country	:	US
Telephone Number	:	208-529-4321
Fax Number	:	208-529-8609

Provider Business Practice Location Address
First Line	:	2515 CHANNING WAY
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7516
Country	:	US
Telephone Number	:	208-529-4321
Fax Number	:	208-529-8609

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. DUANE KENT GODFREY
Credential	:	DDS
Telephone Number	:	208-529-4321

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	12/17/2010

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Directions to “EXCELLENCE IN DENTISTRY PA ” Practice Location

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