Provider Demographics
NPI:1164522306
Name:GOOSE RIVER DENTAL ASSOC., PC
Entity Type:Organization
Organization Name:GOOSE RIVER DENTAL ASSOC., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:LAUF
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-788-4064
Mailing Address - Street 1:37 1/2 MAIN ST E
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:ND
Mailing Address - Zip Code:58257
Mailing Address - Country:US
Mailing Address - Phone:701-788-4064
Mailing Address - Fax:701-788-9090
Practice Address - Street 1:37 1/2 MAIN ST E
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:ND
Practice Address - Zip Code:58257
Practice Address - Country:US
Practice Address - Phone:701-788-4064
Practice Address - Fax:701-788-9090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41080Medicaid