Provider Demographics
NPI:1184300766
Name:GOETHE, JACKSON PONTZ (DDS)
Entity type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:PONTZ
Last Name:GOETHE
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 1:2229 MAPLELEAF DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6715
Mailing Address - Country:US
Mailing Address - Phone:989-859-9333
Mailing Address - Fax:
Practice Address - Street 1:7373 E 21ST ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-1753
Practice Address - Country:US
Practice Address - Phone:317-357-7373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12014137A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist