Provider Demographics
NPI:1194928036
Name:GORECTKE, ROGER JOHN (DDS)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:JOHN
Last Name:GORECTKE
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:PO BOX 1130
Mailing Address - Street 2:
Mailing Address - City:WOODRUFF
Mailing Address - State:WI
Mailing Address - Zip Code:54568-1130
Mailing Address - Country:US
Mailing Address - Phone:715-356-6339
Mailing Address - Fax:715-356-6355
Practice Address - Street 1:110 MAPLE STREET
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:WI
Practice Address - Zip Code:54568-1130
Practice Address - Country:US
Practice Address - Phone:815-356-6339
Practice Address - Fax:715-356-6355
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37960151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice