Provider Demographics
NPI:1134807878
Name:MODERN DENTISTRY OF MINNETONKA PLLC
Entity type:Organization
Organization Name:MODERN DENTISTRY OF MINNETONKA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHASE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GOTTSCHALK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:763-568-9668
Mailing Address - Street 1:2000 PLYMOUTH RD STE 357
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-2335
Mailing Address - Country:US
Mailing Address - Phone:952-544-1449
Mailing Address - Fax:
Practice Address - Street 1:2000 PLYMOUTH RD STE 357
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-2335
Practice Address - Country:US
Practice Address - Phone:952-544-1449
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty