Provider Demographics
NPI:1225565724
Name:GOLER, COURTNEY MARIE
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:MARIE
Last Name:GOLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5375 RAINBOW CLIFF PL
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-5547
Mailing Address - Country:US
Mailing Address - Phone:928-308-3237
Mailing Address - Fax:
Practice Address - Street 1:3626 CROSSINGS DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7137
Practice Address - Country:US
Practice Address - Phone:928-445-5959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-15
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ015301223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program