Provider Demographics
NPI:1447904537
Name:GOTSCHALK, KAITLIN SHIELDS (DMD)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:SHIELDS
Last Name:GOTSCHALK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 RAILROAD AVE UNIT 333
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-3995
Mailing Address - Country:US
Mailing Address - Phone:919-721-4003
Mailing Address - Fax:
Practice Address - Street 1:420 PARK ST STE 101
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NC
Practice Address - Zip Code:28012-3393
Practice Address - Country:US
Practice Address - Phone:704-755-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC127851223P0221X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty