Provider Demographics
NPI:1629356365
Name:GOETZ, NICHOLAS EVAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:EVAN
Last Name:GOETZ
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 1:1600 SW ARCHER RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0371
Mailing Address - Country:US
Mailing Address - Phone:352-273-6901
Mailing Address - Fax:352-846-0248
Practice Address - Street 1:6506 SW 80TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-7592
Practice Address - Country:US
Practice Address - Phone:352-246-1291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 193461223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics