Healthcare Provider Details

I. General information

NPI: 1932870268
Provider Name (Legal Business Name): KATHLEEN SAUCHELLI GORDON DMD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2021
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1378 BROAD ST
CLIFTON NJ
07013-4232
US

IV. Provider business mailing address

1378 BROAD ST
CLIFTON NJ
07013-4232
US

V. Phone/Fax

Practice location:
  • Phone: 973-574-1498
  • Fax:
Mailing address:
  • Phone: 973-574-1498
  • Fax:

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 Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. KATHLEEN SAUCHELLI GORDON
Title or Position: OWNER
Credential: DMD
Phone: 973-574-1498