=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790003960
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREG B GODFREY D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2010
-----------------------------------------------------
Last Update Date | 03/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1186 EASTLAND DR. NORTH STE A
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-733-6074
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1186 EASTLAND DR. NORTH STE A
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-358-3674
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D-4423
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------