Provider Demographics
NPI:1265096812
Name:OTTER CREEK DENTAL, LLC
Entity type:Organization
Organization Name:OTTER CREEK DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOETSCH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:920-740-8706
Mailing Address - Street 1:105 KELLY WAY
Mailing Address - Street 2:
Mailing Address - City:HORTONVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54944-8755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 KELLY WAY
Practice Address - Street 2:
Practice Address - City:HORTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54944-8755
Practice Address - Country:US
Practice Address - Phone:920-740-8706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental