Provider Demographics
NPI:1881602266
Name:EXCELLENCE IN DENTISTRY PA
Entity type:Organization
Organization Name:EXCELLENCE IN DENTISTRY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:GODFREY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-529-4321
Mailing Address - Street 1:2515 CHANNING WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7516
Mailing Address - Country:US
Mailing Address - Phone:208-529-4321
Mailing Address - Fax:208-529-8609
Practice Address - Street 1:2515 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7516
Practice Address - Country:US
Practice Address - Phone:208-529-4321
Practice Address - Fax:208-529-8609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD39831223G0001X
IDD16371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807539000Medicaid
ID000755500Medicaid