Provider Demographics
NPI:1952469355
Name:GODECKI, EWA (DMD)
Entity Type:Individual
Prefix:DR
First Name:EWA
Middle Name:
Last Name:GODECKI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2046 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-5634
Mailing Address - Country:US
Mailing Address - Phone:315-724-1083
Mailing Address - Fax:
Practice Address - Street 1:2046 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5634
Practice Address - Country:US
Practice Address - Phone:315-724-1083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY348861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00559751Medicaid