Provider Demographics
NPI:1407093180
Name:GOECKERMANN, DANIEL ROSS (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:ROSS
Last Name:GOECKERMANN
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 1:2926 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-6706
Mailing Address - Country:US
Mailing Address - Phone:920-452-1031
Mailing Address - Fax:
Practice Address - Street 1:2926 S 12TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081
Practice Address - Country:US
Practice Address - Phone:920-452-1031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-16
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6237-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100001698Medicaid