Provider Demographics
NPI:1730305657
Name:GODDARD, THOMAS LOUIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LOUIS
Last Name:GODDARD
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 1:2600 N MAYFAIR RD
Mailing Address - Street 2:STE 240
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1306
Mailing Address - Country:US
Mailing Address - Phone:414-258-1500
Mailing Address - Fax:414-258-1500
Practice Address - Street 1:3033 W LAYTON AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53221-2628
Practice Address - Country:US
Practice Address - Phone:414-325-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI58781223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics