=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346485265
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOSEPH GOTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2008
-----------------------------------------------------
Last Update Date | 12/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 980 BEAVER GRADE RD
-----------------------------------------------------
City | MOON TOWNSHIP
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15108-2774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-262-5091
-----------------------------------------------------
Fax | 412-262-1090
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 980 BEAVER GRADE RD
-----------------------------------------------------
City | MOON TOWNSHIP
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15108-2774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-262-5091
-----------------------------------------------------
Fax | 412-262-1090
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOSEPH HERMAN GOTH III
-----------------------------------------------------
Credential | DMD, MD
-----------------------------------------------------
Telephone | 412-262-5091
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | MD033127E
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------