Provider Demographics
NPI:1336800697
Name:TOM GODFREY DMD PLLC
Entity Type:Organization
Organization Name:TOM GODFREY DMD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GODFREY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:702-655-9533
Mailing Address - Street 1:4818 W LONE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-2239
Mailing Address - Country:US
Mailing Address - Phone:702-655-9533
Mailing Address - Fax:702-655-9565
Practice Address - Street 1:4818 W LONE MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-2239
Practice Address - Country:US
Practice Address - Phone:702-655-9533
Practice Address - Fax:702-655-9565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV6936Other1063844710