Healthcare Provider Details

I. General information

NPI: 1982922746
Provider Name (Legal Business Name): MARK WILLIAM GORDEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 05/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

754 E CITRUS AVE REDLANDS
REDLANDS CA
92374
US

IV. Provider business mailing address

754 E CITRUS AVE
REDLANDS CA
92374
US

V. Phone/Fax

Practice location:
  • Phone: 909-793-8840
  • Fax: 909-793-8840
Mailing address:
  • Phone: 909-793-1158
  • Fax: 909-793-8840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number26067
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: