Healthcare Provider Details

I. General information

NPI: 1871764233
Provider Name (Legal Business Name): SUSAN ANN GODWIN D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16216 BAXTER RD SUITE 250
CHESTERFIELD MO
63017-4770
US

IV. Provider business mailing address

16216 BAXTER RD SUITE 250
CHESTERFIELD MO
63017-4770
US

V. Phone/Fax

Practice location:
  • Phone: 636-532-3525
  • Fax:
Mailing address:
  • Phone: 636-532-3525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number013223
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: