Provider Demographics
NPI:1487765822
Name:GOETTSCH, GORDON F (DDS)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:F
Last Name:GOETTSCH
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 1:120 E FAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:IA
Mailing Address - Zip Code:52057-1705
Mailing Address - Country:US
Mailing Address - Phone:563-927-4746
Mailing Address - Fax:563-927-6217
Practice Address - Street 1:120 E FAYETTE ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:IA
Practice Address - Zip Code:52057-1705
Practice Address - Country:US
Practice Address - Phone:563-927-4746
Practice Address - Fax:563-927-6217
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA6119122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1129577Medicaid
IA45931Medicare UPIN