Healthcare Provider Details

I. General information

NPI: 1497870646
Provider Name (Legal Business Name): JEREMIAH DANIEL GORDON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 02/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 JENKINS ST SUITE 105A
ST AUGUSTINE FL
32086-5175
US

IV. Provider business mailing address

53 WILLOW DR
ST AUGUSTINE FL
32080-5936
US

V. Phone/Fax

Practice location:
  • Phone: 904-460-0999
  • Fax: 904-460-0999
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN16348
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: