Provider Demographics
NPI:1427141340
Name:GOELLER III, VICTOR RUSSELL III (DMD)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:RUSSELL
Last Name:GOELLER III
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
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?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7811189OtherUNITED CONCORDIA
FL54999OtherBCBS