Provider Demographics
NPI:1265931703
Name:GOSHORN, MARY ELIZABETH (PHDH, RDH)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:GOSHORN
Suffix:
Gender:F
Credentials:PHDH, RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4921 ARCH ROCK RD
Mailing Address - Street 2:
Mailing Address - City:MIFFLINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17059-9080
Mailing Address - Country:US
Mailing Address - Phone:717-829-6968
Mailing Address - Fax:
Practice Address - Street 1:46 RED HILL CT
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:PA
Practice Address - Zip Code:17074-8706
Practice Address - Country:US
Practice Address - Phone:717-230-3919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-11
Last Update Date:2018-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPHDH000740125K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125K00000XDental ProvidersAdvanced Practice Dental Therapist