=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396528881
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GODEL & ASSOCIATES IV PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2023
-----------------------------------------------------
Last Update Date | 08/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1303 DOVE ST
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28112-5012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-689-1412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6655 E WILKINSON BLVD
-----------------------------------------------------
City | BELMONT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28012-4706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-689-1412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATIONS MANAGER
-----------------------------------------------------
Name | ERICA BEACH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-689-1412
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------