Healthcare Provider Details

I. General information

NPI: 1710189055
Provider Name (Legal Business Name): GOSHEN FAMILY DENTISTRY, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 02/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6782 GOSHEN RD
GOSHEN OH
45122-9317
US

IV. Provider business mailing address

6782 GOSHEN RD
GOSHEN OH
45122-9317
US

V. Phone/Fax

Practice location:
  • Phone: 513-722-2933
  • Fax: 513-722-2923
Mailing address:
  • Phone: 513-722-2933
  • Fax: 513-722-2923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number16397
License Number StateOH

VIII. Authorized Official

Name: DR. BRADLEY C BRENNECKE
Title or Position: MANAGER
Credential: DDS
Phone: 513-722-2933