MEDICARE: NICOLE T GORDON, DMD, PLC

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	261QD0000X	Dental Clinic/Center	263787324	FL

General Provider Information

NPI Number	:	1720224074
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NICOLE T GORDON, DMD, PLC

Provider Business Mailing Address
First Line	:	1301 ENISWOOD PKWY
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34683-2027
Country	:	US
Telephone Number	:	727-724-4227
Fax Number	:

Provider Business Practice Location Address
First Line	:	691 ALDERMAN RD
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34683-2602
Country	:	US
Telephone Number	:	727-724-4227
Fax Number	:

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	DR. NICOLE T GORDON
Credential	:	DMD
Telephone Number	:	727-724-4227

Provider Enumeration Date	:	12/16/2008
Last Update Date	:	12/16/2008

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