Provider Demographics
NPI:1710916713
Name:GOEDECKE, MARK ANTHONIE (DMD, FAGD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONIE
Last Name:GOEDECKE
Suffix:
Gender:M
Credentials:DMD, FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 LONG POINT RD STE B
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-8287
Mailing Address - Country:US
Mailing Address - Phone:843-971-9594
Mailing Address - Fax:843-971-3034
Practice Address - Street 1:709 LONG POINT RD STE B
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-8287
Practice Address - Country:US
Practice Address - Phone:843-971-9594
Practice Address - Fax:843-971-3034
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC34981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice