Provider Demographics
NPI:1407948920
Name:GODFREY, THOMAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:GODFREY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:P
Other - Last Name:GODFREY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:3401 NORTHSIDE PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-2323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3401 NORTHSIDE PKWY NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-2323
Practice Address - Country:US
Practice Address - Phone:999-999-9999
Practice Address - Fax:888-888-8888
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011176122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA011176OtherSTATE LICENSE