Healthcare Provider Details

I. General information

NPI: 1023015401
Provider Name (Legal Business Name): GORDON K. JONES DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 12/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 N MCKINLEY RD
LAKE FOREST IL
60045-1377
US

IV. Provider business mailing address

1541 N MCKINLEY RD
LAKE FOREST IL
60045-1377
US

V. Phone/Fax

Practice location:
  • Phone: 847-502-0197
  • Fax:
Mailing address:
  • Phone: 847-502-0197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019-019499
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number004212
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: