Healthcare Provider Details

I. General information

NPI: 1215190731
Provider Name (Legal Business Name): DR. MANUEL BARRY GORDON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MANUEL BARRY GORDON DDS

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 W PLEASANTVIEW AVE STE 14A
HACKENSACK NJ
07601-8004
US

IV. Provider business mailing address

160 E 91ST ST 2N
NEW YORK NY
10128-2452
US

V. Phone/Fax

Practice location:
  • Phone: 646-483-4470
  • Fax:
Mailing address:
  • Phone: 646-483-4470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number22DI02185100
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: