Healthcare Provider Details

I. General information

NPI: 1356562631
Provider Name (Legal Business Name): GOSHEN COSMETIC AND ADVANCED FAMILY DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 CHARLTON CT
GOSHEN IN
46526-6464
US

IV. Provider business mailing address

1801 CHARLTON CT
GOSHEN IN
46526-6464
US

V. Phone/Fax

Practice location:
  • Phone: 574-533-8934
  • Fax: 574-533-9487
Mailing address:
  • Phone: 574-533-8934
  • Fax: 574-533-9487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. CHAD G. STUTSMAN
Title or Position: OWNER
Credential: DDS
Phone: 574-533-8934