Provider Demographics
NPI:1265215594
Name:GODDARD, JONATHON (DMD)
Entity type:Individual
Prefix:DR
First Name:JONATHON
Middle Name:
Last Name:GODDARD
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 1:1615 HERMANN DR UNIT 1234
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-7148
Mailing Address - Country:US
Mailing Address - Phone:503-487-7948
Mailing Address - Fax:
Practice Address - Street 1:4003 RUSTIC WOODS DR STE E
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-2600
Practice Address - Country:US
Practice Address - Phone:281-360-3630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-18
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39935122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist