Provider Demographics
NPI:1154311298
Name:GOTHELF, CRAIG (DDS)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:
Last Name:GOTHELF
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 1:3730 83RD ST
Mailing Address - Street 2:DENTAL OFFICE
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-7154
Mailing Address - Country:US
Mailing Address - Phone:718-639-6966
Mailing Address - Fax:718-639-8478
Practice Address - Street 1:3730 83RD ST
Practice Address - Street 2:DENTAL OFFICE
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7154
Practice Address - Country:US
Practice Address - Phone:718-639-6966
Practice Address - Fax:718-639-8478
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0375741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00780570Medicaid