Healthcare Provider Details

I. General information

NPI: 1578762076
Provider Name (Legal Business Name): PATRICIA LYNN GORDON-WILLIS D.M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2643 RANDLEMAN RD
GREENSBORO NC
27406-5153
US

IV. Provider business mailing address

302 N EUGENE ST APT 311
GREENSBORO NC
27401-3398
US

V. Phone/Fax

Practice location:
  • Phone: 336-544-2758
  • Fax:
Mailing address:
  • Phone: 601-212-5917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN014937
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN1000945
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number12416
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: