Healthcare Provider Details

I. General information

NPI: 1366558546
Provider Name (Legal Business Name): MICHAEL A. GORDON, DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

829 MAIN ST
SCHERERVILLE IN
46375-1100
US

IV. Provider business mailing address

829 MAIN ST
SCHERERVILLE IN
46375-1100
US

V. Phone/Fax

Practice location:
  • Phone: 219-322-1929
  • Fax:
Mailing address:
  • Phone: 219-322-1929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number54001287A
License Number StateIN

VIII. Authorized Official

Name: DR. MICHAEL ANTHONY GORDON
Title or Position: PRESIDENT
Credential: DDS
Phone: 219-322-1929