Provider Demographics
NPI:1063144350
Name:GODWIN, MADISON PARKER (DMD)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:PARKER
Last Name:GODWIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 KNOTTY PINE CT
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-4190
Mailing Address - Country:US
Mailing Address - Phone:910-918-5678
Mailing Address - Fax:
Practice Address - Street 1:2520 DELANEY AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6002
Practice Address - Country:US
Practice Address - Phone:910-762-1772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12852122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA