Provider Demographics
NPI:1235020462
Name:GODFREY, HAYDAN MARSHALL (DDS)
Entity type:Individual
Prefix:DR
First Name:HAYDAN
Middle Name:MARSHALL
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 1:583 E BONITA AVE APT A
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3175
Mailing Address - Country:US
Mailing Address - Phone:909-632-8011
Mailing Address - Fax:
Practice Address - Street 1:10501 LAKEWOOD BLVD
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-2709
Practice Address - Country:US
Practice Address - Phone:562-372-2722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-15
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111747122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist