Provider Demographics
NPI:1255312641
Name:GOTHELF, ERIC PAUL (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:PAUL
Last Name:GOTHELF
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6121 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-3569
Mailing Address - Country:US
Mailing Address - Phone:718-458-0940
Mailing Address - Fax:718-458-1319
Practice Address - Street 1:6121 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3569
Practice Address - Country:US
Practice Address - Phone:718-458-0940
Practice Address - Fax:718-458-1319
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040189122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00983537Medicaid