Provider Demographics
NPI:1215107248
Name:D. MICHAEL GOEBEL D.D.S., PC
Entity type:Organization
Organization Name:D. MICHAEL GOEBEL D.D.S., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GOEBEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-258-8509
Mailing Address - Street 1:407 E AVENUE C
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-3942
Mailing Address - Country:US
Mailing Address - Phone:701-258-8509
Mailing Address - Fax:
Practice Address - Street 1:407 E AVENUE C
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-3942
Practice Address - Country:US
Practice Address - Phone:701-258-8509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND17671223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41027Medicaid