Provider Demographics
NPI:1902211725
Name:GODBOLT, EMERSON G (DMD)
Entity Type:Individual
Prefix:DR
First Name:EMERSON
Middle Name:G
Last Name:GODBOLT
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 1:1310 PONDEROSA DR STE A
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-5073
Mailing Address - Country:US
Mailing Address - Phone:208-263-7641
Mailing Address - Fax:406-452-4064
Practice Address - Street 1:1310 PONDEROSA DR STE A
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-5073
Practice Address - Country:US
Practice Address - Phone:208-263-7641
Practice Address - Fax:208-265-4333
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-01
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID52191223G0001X
MT7811122300000X
MTDEN-DEN-LIC-7811122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist