Healthcare Provider Details

I. General information

NPI: 1326030990
Provider Name (Legal Business Name): JOHN RAY GORDON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 11/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 CAMINO DEL RIO N STE 140
SAN DIEGO CA
92108-1633
US

IV. Provider business mailing address

3814 CORRAL CANYON RD
BONITA CA
91902-2806
US

V. Phone/Fax

Practice location:
  • Phone: 619-282-7088
  • Fax: 619-282-6290
Mailing address:
  • Phone: 619-267-1662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number51878
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4183
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: