Healthcare Provider Details

I. General information

NPI: 1255962130
Provider Name (Legal Business Name): GORDON & GORDON, DMD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 NEW MARKET BLVD STE 4
BOONE NC
28607-5501
US

IV. Provider business mailing address

450 NEW MARKET BLVD STE 4
BOONE NC
28607-5501
US

V. Phone/Fax

Practice location:
  • Phone: 828-386-1388
  • Fax: 828-386-1446
Mailing address:
  • Phone: 828-386-1388
  • Fax: 828-386-1446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. DANIELLE D GORDON
Title or Position: VICE PRESIDENT
Credential: DMD
Phone: 828-434-3333