Provider Demographics
NPI:1487757308
Name:GORDON, DAVID MICHAEL (DDS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:GORDON
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 1:823 BANTRY COURT
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510
Mailing Address - Country:US
Mailing Address - Phone:707-745-1344
Mailing Address - Fax:707-642-7502
Practice Address - Street 1:23 ROTARY WAY
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94591-8475
Practice Address - Country:US
Practice Address - Phone:707-557-2200
Practice Address - Fax:707-642-7502
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31465122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist