Provider Demographics
NPI:1821258260
Name:GOECKERITZ, CHAD MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:MICHAEL
Last Name:GOECKERITZ
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 1:2120 E 3900 S
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1771
Mailing Address - Country:US
Mailing Address - Phone:801-274-2500
Mailing Address - Fax:801-274-0590
Practice Address - Street 1:2120 E 3900 S
Practice Address - Street 2:SUITE 102
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1771
Practice Address - Country:US
Practice Address - Phone:801-274-2500
Practice Address - Fax:801-274-0590
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7015094-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice