Healthcare Provider Details

I. General information

NPI: 1336502145
Provider Name (Legal Business Name): GARY L. GOTSCH DDS, MSD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 10/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4205 HOBSON CT
FORT WAYNE IN
46815-8648
US

IV. Provider business mailing address

4205 HOBSON CT
FORT WAYNE IN
46815-8648
US

V. Phone/Fax

Practice location:
  • Phone: 260-486-8788
  • Fax: 260-486-7679
Mailing address:
  • Phone: 260-486-8778
  • Fax: 260-486-7679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number7341
License Number StateIN

VIII. Authorized Official

Name: DR. GARY L GOTSCH
Title or Position: OWNER/DENTIST
Credential:
Phone: 260-486-8778