Provider Demographics
NPI:1174627749
Name:GOTSCH, GARY LYNN (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LYNN
Last Name:GOTSCH
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 HOBSON CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-8648
Mailing Address - Country:US
Mailing Address - Phone:260-486-8778
Mailing Address - Fax:260-486-7679
Practice Address - Street 1:4205 HOBSON CT
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-8648
Practice Address - Country:US
Practice Address - Phone:260-486-8778
Practice Address - Fax:260-486-7679
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN73411223P0700X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100181210AMedicaid
INT92321Medicare UPIN
IN100181210AMedicaid
IN0216990001Medicare NSC