Basic Information
Provider Information
NPI: 1003004698
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GODFREY
FirstName: MERLE
MiddleName: FRANKLIN
NamePrefix: DR.
NameSuffix: III
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 2178
Address2:  
City: LOOMIS
State: CA
PostalCode: 956502178
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 3669 TAYLOR RD
Address2: #2178
City: LOOMIS
State: CA
PostalCode: 956507400
CountryCode: US
TelephoneNumber: 9166600907
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/09/2007
LastUpdateDate: 04/18/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X38684CAY Dental ProvidersDentistGeneral Practice

No ID Information.


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