1164694311 NPI number — MICHAEL L GORDON DMD INC

Table of content: (NPI 1164694311)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164694311 NPI number — MICHAEL L GORDON DMD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL L GORDON DMD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164694311
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3544 SPRINGDALE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45251-1331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-385-6555
Provider Business Mailing Address Fax Number:
513-385-2833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3544 SPRINGDALE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45251-1331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-385-6555
Provider Business Practice Location Address Fax Number:
513-385-2833
Provider Enumeration Date:
03/27/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GORDON
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
LEWIS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
513-385-6555

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  30014084 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0215565 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".