Provider Demographics
NPI:1023449352
Name:GORDON, COLLEEN MOHAN (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:MOHAN
Last Name:GORDON
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:37 ISABELLE CT
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-5623
Mailing Address - Country:US
Mailing Address - Phone:267-360-0777
Mailing Address - Fax:
Practice Address - Street 1:545 N BETHLEHEM PIKE STE 205
Practice Address - Street 2:
Practice Address - City:AMBLER
Practice Address - State:PA
Practice Address - Zip Code:19002-2557
Practice Address - Country:US
Practice Address - Phone:267-360-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2020-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0425221223X0400X
NJ22DI025939001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics