Provider Demographics
NPI:1275605933
Name:GODFREY, MICHAEL WYNN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WYNN
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 1:1980 BIRDIE THOMPSON DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2755
Mailing Address - Country:US
Mailing Address - Phone:208-233-8750
Mailing Address - Fax:208-233-8751
Practice Address - Street 1:1980 BIRDIE THOMPSON DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2755
Practice Address - Country:US
Practice Address - Phone:208-233-8750
Practice Address - Fax:208-233-8751
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-39011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice