Provider Demographics
NPI:1215376504
Name:GODFREY, MATTHEW P (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:P
Last Name:GODFREY
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 1:1598 DELPHIC WAY
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2232
Mailing Address - Country:US
Mailing Address - Phone:208-637-1300
Mailing Address - Fax:208-637-0798
Practice Address - Street 1:1598 DELPHIC WAY
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2232
Practice Address - Country:US
Practice Address - Phone:208-637-1300
Practice Address - Fax:208-637-0798
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-19
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4490122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist