Healthcare Provider Details

I. General information

NPI: 1730421470
Provider Name (Legal Business Name): GARETT CHARLES GODFREY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2013
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 HARRISON AVE
CENTRALIA WA
98531-2109
US

IV. Provider business mailing address

2690 NE KRESKY AVE
CHEHALIS WA
98532-2412
US

V. Phone/Fax

Practice location:
  • Phone: 607-365-4053
  • Fax: 360-736-5620
Mailing address:
  • Phone: 360-330-9595
  • Fax: 360-330-9580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60646168
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: