Provider Demographics
NPI:1730421470
Name:GODFREY, GARETT CHARLES (DDS)
Entity type:Individual
Prefix:
First Name:GARETT
Middle Name:CHARLES
Last Name:GODFREY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2690 NE KRESKY AVE
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-2412
Mailing Address - Country:US
Mailing Address - Phone:360-330-9595
Mailing Address - Fax:360-330-9580
Practice Address - Street 1:711 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-2109
Practice Address - Country:US
Practice Address - Phone:607-365-4053
Practice Address - Fax:360-736-5620
Is Sole Proprietor?:No
Enumeration Date:2013-03-20
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60646168122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2029032Medicaid