Healthcare Provider Details

I. General information

NPI: 1801999719
Provider Name (Legal Business Name): JOHN GORDON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 03/04/2026
Certification Date: 03/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 CARLETON AVE SUITE 1
ISLIP TERRACE NY
11752-2236
US

IV. Provider business mailing address

111 CARLETON AVE STE 1
ISLIP TERRACE NY
11752-2236
US

V. Phone/Fax

Practice location:
  • Phone: 631-581-3500
  • Fax: 631-581-4723
Mailing address:
  • Phone: 631-581-3500
  • Fax: 631-581-4723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number044635
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number044635
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number044635
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: