Healthcare Provider Details

I. General information

NPI: 1679693550
Provider Name (Legal Business Name): GORDON MARVIN RICK DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DR. GORDON RICK

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5190 GOVERNOR DR SUITE 106
SAN DIEGO CA
92122-2847
US

IV. Provider business mailing address

5190 GOVERNOR DR SUITE 106
SAN DIEGO CA
92122-2847
US

V. Phone/Fax

Practice location:
  • Phone: 858-784-0600
  • Fax: 858-784-0604
Mailing address:
  • Phone: 858-784-0600
  • Fax: 858-784-0604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number20041
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: