Healthcare Provider Details

I. General information

NPI: 1750516159
Provider Name (Legal Business Name): STEPHANIE SPURLOCK GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2009
Last Update Date: 05/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 NW 119TH ST
MIAMI FL
33167-3231
US

IV. Provider business mailing address

282 NE 54TH ST APT 1
MIAMI FL
33137-2822
US

V. Phone/Fax

Practice location:
  • Phone: 305-685-7863
  • Fax:
Mailing address:
  • Phone: 786-344-6583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number18410
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH 18410
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: