Basic Information
| Provider Information | |||||||||
| NPI: | 1730421470 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GODFREY | ||||||||
| FirstName: | GARETT | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2690 NE KRESKY AVE | ||||||||
| Address2: | |||||||||
| City: | CHEHALIS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985322412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603309595 | ||||||||
| FaxNumber: | 3603309580 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 HARRISON AVE | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985312109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6073654053 | ||||||||
| FaxNumber: | 3607365620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2013 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DE60646168 | WA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 2029032 | 05 | WA | MEDICAID |