MEDICARE: TOM GODFREY DMD PLLC

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

General Provider Information

NPI Number	:	1982568432
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOM GODFREY DMD PLLC

Provider Business Mailing Address
First Line	:	4818 W LONE MOUNTAIN RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-2239
Country	:	US
Telephone Number	:	702-655-9533
Fax Number	:	702-655-9565

Provider Business Practice Location Address
First Line	:	4818 W LONE MOUNTAIN RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-2239
Country	:	US
Telephone Number	:	702-655-9533
Fax Number	:	702-655-9565

Authorized Official
Title or Position	:	MANAGER
Name	:	BETTY VILLASENOR
Credential	:
Telephone Number	:	702-655-9533

Provider Enumeration Date	:	12/10/2025
Last Update Date	:	12/10/2025

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