Provider Demographics
NPI:1316374200
Name:GODISAK, TINA (RDH)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:GODISAK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4222
Mailing Address - Street 2:
Mailing Address - City:TELLURIDE
Mailing Address - State:CO
Mailing Address - Zip Code:81435
Mailing Address - Country:US
Mailing Address - Phone:719-480-3822
Mailing Address - Fax:888-595-3242
Practice Address - Street 1:220 E COLORADO AVE STE 106
Practice Address - Street 2:
Practice Address - City:TELLURIDE
Practice Address - State:CO
Practice Address - Zip Code:81435
Practice Address - Country:US
Practice Address - Phone:719-480-3822
Practice Address - Fax:888-595-3242
Is Sole Proprietor?:No
Enumeration Date:2013-10-09
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO904579124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist