Provider Demographics
NPI:1821149253
Name:GOELZ, ROBERT JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JOHN
Last Name:GOELZ
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 1:1052 BEL AIRE CT
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5015
Mailing Address - Country:US
Mailing Address - Phone:920-499-8711
Mailing Address - Fax:920-499-9903
Practice Address - Street 1:1052 BEL AIRE CT
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5015
Practice Address - Country:US
Practice Address - Phone:920-499-8711
Practice Address - Fax:920-499-9903
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50008981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33541100Medicaid