Provider Demographics
NPI:1568187052
Name:GOLTZ, ELISABETH KATHLEEN
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:KATHLEEN
Last Name:GOLTZ
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 1:3670 WINDFALL PASS RD
Mailing Address - Street 2:
Mailing Address - City:PLUMMER
Mailing Address - State:ID
Mailing Address - Zip Code:83851-6011
Mailing Address - Country:US
Mailing Address - Phone:208-661-1312
Mailing Address - Fax:
Practice Address - Street 1:427 12TH STREET
Practice Address - Street 2:PLUMMER
Practice Address - City:IDAHO
Practice Address - State:ID
Practice Address - Zip Code:83851
Practice Address - Country:US
Practice Address - Phone:208-686-1931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDH-1771124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist