Provider Demographics
NPI:1629502216
Name:GOETZ, CASEY (DDS)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:GOETZ
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 1:140 TWIN RIVERS CT
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-2015
Mailing Address - Country:US
Mailing Address - Phone:320-257-3380
Mailing Address - Fax:
Practice Address - Street 1:91 TROY SQ STE 201
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-3228
Practice Address - Country:US
Practice Address - Phone:636-383-4500
Practice Address - Fax:636-383-4501
Is Sole Proprietor?:No
Enumeration Date:2017-04-20
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA09417390200000X
IADDS-094171223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program