Provider Demographics
NPI:1407871387
Name:GOETTSCH, EVA M (DDS)
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:M
Last Name:GOETTSCH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 INDIAN ST
Mailing Address - Street 2:
Mailing Address - City:CHEROKEE
Mailing Address - State:IA
Mailing Address - Zip Code:51012-1272
Mailing Address - Country:US
Mailing Address - Phone:712-225-0432
Mailing Address - Fax:712-225-1981
Practice Address - Street 1:110 INDIAN ST
Practice Address - Street 2:
Practice Address - City:CHEROKEE
Practice Address - State:IA
Practice Address - Zip Code:51012-1272
Practice Address - Country:US
Practice Address - Phone:712-225-0432
Practice Address - Fax:712-225-1981
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA77931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1138313Medicaid
IA7793OtherDDS LICENSE #