Provider Demographics
NPI:1336260843
Name:GOCKE, MICHAEL TIMOTHY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:TIMOTHY
Last Name:GOCKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 645205
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15264-5205
Mailing Address - Country:US
Mailing Address - Phone:866-756-3200
Mailing Address - Fax:479-725-2395
Practice Address - Street 1:7601 LEWINSVILLE RD
Practice Address - Street 2:SUITE 203
Practice Address - City:MCLEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-2814
Practice Address - Country:US
Practice Address - Phone:703-388-2805
Practice Address - Fax:703-388-2806
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014115381223S0112X, 204E00000X, 2082S0099X
WV35851223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9200594Medicaid