Provider Demographics
NPI:1619038940
Name:GODICK, BRUCE H (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:H
Last Name:GODICK
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:FAIRVIEW ROAD AT 5TH AVE.
Mailing Address - Street 2:
Mailing Address - City:WOODLYN
Mailing Address - State:PA
Mailing Address - Zip Code:19094
Mailing Address - Country:US
Mailing Address - Phone:610-833-2660
Mailing Address - Fax:610-833-5833
Practice Address - Street 1:FAIRVIEW ROAD AT 5TH AVE.
Practice Address - Street 2:
Practice Address - City:WOODLYN
Practice Address - State:PA
Practice Address - Zip Code:19094
Practice Address - Country:US
Practice Address - Phone:610-833-2660
Practice Address - Fax:610-833-5833
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA21158-L1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics