Provider Demographics
NPI:1356562631
Name:GOSHEN COSMETIC AND ADVANCED FAMILY DENTISTRY PC
Entity type:Organization
Organization Name:GOSHEN COSMETIC AND ADVANCED FAMILY DENTISTRY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:G
Authorized Official - Last Name:STUTSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:574-533-8934
Mailing Address - Street 1:1801 CHARLTON CT
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-6464
Mailing Address - Country:US
Mailing Address - Phone:574-533-8934
Mailing Address - Fax:574-533-9487
Practice Address - Street 1:1801 CHARLTON CT
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-6464
Practice Address - Country:US
Practice Address - Phone:574-533-8934
Practice Address - Fax:574-533-9487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty