=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134807878
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODERN DENTISTRY OF MINNETONKA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2023
-----------------------------------------------------
Last Update Date | 07/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2000 PLYMOUTH RD STE 357
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55305-2335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-544-1449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2000 PLYMOUTH RD STE 357
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55305-2335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-544-1449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER/DENTIST
-----------------------------------------------------
Name | DR. CHASE JAMES GOTTSCHALK
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 763-568-9668
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------