Provider Demographics
NPI:1609945419
Name:GOETTISHEIM, LAWRENCE EDWARD (DDS)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:EDWARD
Last Name:GOETTISHEIM
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 1:103 SOUTH BEDFORD RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MT KISCO
Mailing Address - State:NY
Mailing Address - Zip Code:10549-3452
Mailing Address - Country:US
Mailing Address - Phone:914-241-7670
Mailing Address - Fax:914-241-7254
Practice Address - Street 1:103 SOUTH BEDFORD RD
Practice Address - Street 2:SUITE 110
Practice Address - City:MT KISCO
Practice Address - State:NY
Practice Address - Zip Code:10549-3452
Practice Address - Country:US
Practice Address - Phone:914-241-7670
Practice Address - Fax:914-241-7254
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0393361223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics