Healthcare Provider Details

I. General information

NPI: 1821201518
Provider Name (Legal Business Name): GLENN P GODART DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 08/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 BERGEN ST
NEWARK NJ
07101-1709
US

IV. Provider business mailing address

88 SHERWOOD RD
RIDGEWOOD NJ
07450-1320
US

V. Phone/Fax

Practice location:
  • Phone: 973-972-4615
  • Fax:
Mailing address:
  • Phone: 201-447-4894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI01155300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: