MEDICARE: DR. GORDON D. KORTHALS D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	4375-015	WI

General Provider Information

NPI Number	:	1235271792
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GORDON D. KORTHALS D.D.S.

Provider Business Mailing Address
First Line	:	600 S. MAIN ST.
Second Line	:
City	:	OSHKOSH
State	:	WI
Zip	:	54902
Country	:	US
Telephone Number	:	920-233-8882
Fax Number	:	920-303-2736

Provider Business Practice Location Address
First Line	:	600 S MAIN ST
Second Line	:
City	:	OSHKOSH
State	:	WI
Zip	:	54902-6074
Country	:	US
Telephone Number	:	920-233-8882
Fax Number	:	920-303-2736

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	07/08/2007

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