Provider Demographics
NPI:1174602262
Name:BRETT S. GOYMERAC DDS PC
Entity type:Organization
Organization Name:BRETT S. GOYMERAC DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOYMERAC
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:906-228-4646
Mailing Address - Street 1:760 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4138
Mailing Address - Country:US
Mailing Address - Phone:906-228-4646
Mailing Address - Fax:906-228-4166
Practice Address - Street 1:760 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4138
Practice Address - Country:US
Practice Address - Phone:906-228-4646
Practice Address - Fax:906-228-4166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID801178OtherBLUE CROSS BLUE SHIELD