Provider Demographics
NPI:1336502145
Name:GARY L. GOTSCH DDS, MSD, LLC
Entity Type:Organization
Organization Name:GARY L. GOTSCH DDS, MSD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GOTSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-486-8778
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:260-486-8788
Practice Address - Fax:260-486-7679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-30
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223P0700X
IN7341332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty