Provider Demographics
NPI:1427132240
Name:GOEDEKER, JEFFREY PAUL
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:PAUL
Last Name:GOEDEKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7622 SERGI CANYON DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46217-7174
Mailing Address - Country:US
Mailing Address - Phone:317-859-3580
Mailing Address - Fax:
Practice Address - Street 1:8190 WINDFALL LN STE B
Practice Address - Street 2:
Practice Address - City:CAMBY
Practice Address - State:IN
Practice Address - Zip Code:46113-7907
Practice Address - Country:US
Practice Address - Phone:317-821-0600
Practice Address - Fax:317-821-0606
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010781A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist