Provider Demographics
NPI:1235271792
Name:KORTHALS, GORDON D (DDS)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:D
Last Name:KORTHALS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902
Mailing Address - Country:US
Mailing Address - Phone:920-233-8882
Mailing Address - Fax:920-303-2736
Practice Address - Street 1:600 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-6074
Practice Address - Country:US
Practice Address - Phone:920-233-8882
Practice Address - Fax:920-303-2736
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4375-0151223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics