Healthcare Provider Details

I. General information

NPI: 1174652671
Provider Name (Legal Business Name): MITCHEL S GODAT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6268 POPLAR AVE
MEMPHIS TN
38119-4713
US

IV. Provider business mailing address

6268 POPLAR AVE
MEMPHIS TN
38119-4713
US

V. Phone/Fax

Practice location:
  • Phone: 901-761-3770
  • Fax: 901-761-3775
Mailing address:
  • Phone: 901-761-3770
  • Fax: 901-761-3775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number7731
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: