Healthcare Provider Details

I. General information

NPI: 1053098756
Provider Name (Legal Business Name): ERIKO MITO GORDON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 08/14/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 5071
APO AP
96328-5071
US

IV. Provider business mailing address

UNIT 5071
APO AP
96328-5071
US

V. Phone/Fax

Practice location:
  • Phone: 315-225-3671
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN.00206091
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: