Provider Demographics
NPI:1962854745
Name:GOETTLICHER, CASEY
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:GOETTLICHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37595 7 MILE RD
Mailing Address - Street 2:#450
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:37595 7 MILE RD
Practice Address - Street 2:#450
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1003
Practice Address - Country:US
Practice Address - Phone:734-855-4474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-06
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021989122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1962854745Medicaid