Provider Demographics
NPI:1396048039
Name:GOESSMAN, GREGORY DIETRICH (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:DIETRICH
Last Name:GOESSMAN
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 1:2815 WILLETTA ST SW
Mailing Address - Street 2:STE #A1
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-3470
Mailing Address - Country:US
Mailing Address - Phone:541-924-1086
Mailing Address - Fax:541-924-1174
Practice Address - Street 1:2815 WILLETTA ST SW
Practice Address - Street 2:STE #A1
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-3470
Practice Address - Country:US
Practice Address - Phone:541-924-1086
Practice Address - Fax:541-924-1174
Is Sole Proprietor?:No
Enumeration Date:2010-12-20
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE601753101223G0001X
ORD9546122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice