Provider Demographics
NPI:1306939228
Name:V RUSSELL GOELLER III MD PA
Entity type:Organization
Organization Name:V RUSSELL GOELLER III MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:GOELLER
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-474-1855
Mailing Address - Street 1:2115 W NINE MILE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32534-9470
Mailing Address - Country:US
Mailing Address - Phone:850-474-1855
Mailing Address - Fax:850-478-2845
Practice Address - Street 1:2115 W NINE MILE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32534-9470
Practice Address - Country:US
Practice Address - Phone:850-474-1855
Practice Address - Fax:850-478-2845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15157122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA781189OtherUNITED CONCORDIA
FL54999OtherBCBS