Healthcare Provider Details

I. General information

NPI: 1558815365
Provider Name (Legal Business Name): MAXIM GODKO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FEDERAL CITY RD # 104B
LAWRENCEVILLE NJ
08648-1664
US

IV. Provider business mailing address

561 MONMOUTH RD ROUTE 537
WRIGHTSTOWN NJ
08562-2125
US

V. Phone/Fax

Practice location:
  • Phone: 609-718-7997
  • Fax: 888-575-1408
Mailing address:
  • Phone: 609-758-2244
  • Fax: 609-758-6773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI02643700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: