MEDICARE: DR. ANDREA T. GORDON DDS,LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	013689	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	979390	OTHER	MO	UNITED CONCORDIA
3	3051	OTHER	MO	DENTAQUEST

General Provider Information

NPI Number	:	1073887642
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. ANDREA T. GORDON DDS,LLC

Provider Business Mailing Address
First Line	:	1408 N KINGSHIGHWAY BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63113-1400
Country	:	US
Telephone Number	:	314-361-6767
Fax Number	:	314-361-1480

Provider Business Practice Location Address
First Line	:	1408 N KINGSHIGHWAY BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63113-1400
Country	:	US
Telephone Number	:	314-361-6767
Fax Number	:	314-361-1480

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. ANDREA T. GORDON
Credential	:	D.D.S.
Telephone Number	:	314-361-6767

Provider Enumeration Date	:	02/29/2012
Last Update Date	:	02/29/2012

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