Provider Demographics
NPI:1548619265
Name:GOEKE, CHAD (DMD)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:GOEKE
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 1:101 CAMELOT DR
Mailing Address - Street 2:SUITE #3
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-8048
Mailing Address - Country:US
Mailing Address - Phone:920-921-1244
Mailing Address - Fax:920-921-2192
Practice Address - Street 1:W4173 COUNTY ROAD H
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-9653
Practice Address - Country:US
Practice Address - Phone:815-541-9561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001300-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist