Provider Demographics
NPI:1043270846
Name:GOUCH, JOHN B SR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:GOUCH
Suffix:SR
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 1:3616 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215
Mailing Address - Country:US
Mailing Address - Phone:704-537-6636
Mailing Address - Fax:704-537-5005
Practice Address - Street 1:3616 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215
Practice Address - Country:US
Practice Address - Phone:704-537-6636
Practice Address - Fax:704-537-5005
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8993292Medicaid