Provider Demographics
NPI:1174652671
Name:GODAT, MITCHEL S (DDS)
Entity Type:Individual
Prefix:DR
First Name:MITCHEL
Middle Name:S
Last Name:GODAT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6268 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-4713
Mailing Address - Country:US
Mailing Address - Phone:901-761-3770
Mailing Address - Fax:901-761-3775
Practice Address - Street 1:6268 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4713
Practice Address - Country:US
Practice Address - Phone:901-761-3770
Practice Address - Fax:901-761-3775
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN77311223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics