Provider Demographics
NPI:1891801700
Name:GOEDECKE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:GOEDECKE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANTONIE
Authorized Official - Last Name:GOEDECKE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, FAGD
Authorized Official - Phone:843-971-9594
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
Practice Address - Street 2:STE B
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC34981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty