Provider Demographics
NPI:1871636555
Name:GOTTSCHALL, MARVIN J JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:J
Last Name:GOTTSCHALL
Suffix:JR
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 1:1821 N LECLERC RD. #1
Mailing Address - Street 2:
Mailing Address - City:CUSICK
Mailing Address - State:WA
Mailing Address - Zip Code:99119-5015
Mailing Address - Country:US
Mailing Address - Phone:509-447-7111
Mailing Address - Fax:509-445-1152
Practice Address - Street 1:1821 N LECLERC RD. #1
Practice Address - Street 2:
Practice Address - City:CUSICK
Practice Address - State:WA
Practice Address - Zip Code:99119-5015
Practice Address - Country:US
Practice Address - Phone:509-447-7111
Practice Address - Fax:509-445-1152
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000098011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0213060OtherLABOR & INDUSTRIES ID #
WA5051537Medicaid