Healthcare Provider Details

I. General information

NPI: 1750491866
Provider Name (Legal Business Name): JOHN LYNN GORDON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 SOUTH 8TH
DEMING NM
88030
US

IV. Provider business mailing address

1315 SOUTH 8TH
DEMING NM
88030
US

V. Phone/Fax

Practice location:
  • Phone: 505-546-6591
  • Fax: 505-546-4376
Mailing address:
  • Phone: 505-546-6591
  • Fax: 505-546-4376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDL1352
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: