Provider Demographics
NPI:1063844710
Name:GODFREY, THOMAS HANSEN (DMD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:HANSEN
Last Name:GODFREY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4818 W LONE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-2239
Mailing Address - Country:US
Mailing Address - Phone:702-655-9533
Mailing Address - Fax:
Practice Address - Street 1:1580 E DESERT INN RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-2548
Practice Address - Country:US
Practice Address - Phone:702-466-2507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVD-69361223G0001X
IDD-4441122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist