Healthcare Provider Details

I. General information

NPI: 1356365126
Provider Name (Legal Business Name): MARK RICHARD GORDON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 11/28/2020
Certification Date: 11/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W 12TH AVE
COLUMBUS OH
43210-1267
US

IV. Provider business mailing address

305 W 12TH AVE
COLUMBUS OH
43210-1267
US

V. Phone/Fax

Practice location:
  • Phone: 614-688-3763
  • Fax:
Mailing address:
  • Phone: 614-688-3763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberVA6393
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number14432
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number14332
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: