Provider Demographics
NPI:1053436816
Name:GODDERIDGE, BRUCE H (DMD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:H
Last Name:GODDERIDGE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:291 SO MAIN
Mailing Address - Street 2:SUITE A
Mailing Address - City:SMITHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84335
Mailing Address - Country:US
Mailing Address - Phone:435-563-6213
Mailing Address - Fax:435-563-8443
Practice Address - Street 1:291 SOUTH MAIN
Practice Address - Street 2:SUITE A
Practice Address - City:SMITHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84335
Practice Address - Country:US
Practice Address - Phone:435-563-6213
Practice Address - Fax:435-563-8443
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1431759922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist