Healthcare Provider Details

I. General information

NPI: 1053405118
Provider Name (Legal Business Name): MELINDA P. GORDON D.M.D. A DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16935 VANOWEN ST. SUITE A
LAKE BALBOA CA
91406
US

IV. Provider business mailing address

16935 VANOWEN ST. SUITE A
LAKE BALBOA CA
91406
US

V. Phone/Fax

Practice location:
  • Phone: 818-705-2931
  • Fax: 818-344-9565
Mailing address:
  • Phone: 818-705-2931
  • Fax: 818-344-9565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number32605
License Number StateCA

VIII. Authorized Official

Name: DR. MELINDA PIEGA GORDON
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 818-705-2931