Provider Demographics
NPI:1366561680
Name:POELMAN, GORDON WILLIAM (DDS)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:WILLIAM
Last Name:POELMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15525 POMERADO RD
Mailing Address - Street 2:D-6
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2435
Mailing Address - Country:US
Mailing Address - Phone:858-487-1234
Mailing Address - Fax:858-487-1235
Practice Address - Street 1:15525 POMERADO RD
Practice Address - Street 2:D-6
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2435
Practice Address - Country:US
Practice Address - Phone:858-487-1234
Practice Address - Fax:858-487-1235
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA402951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice