Healthcare Provider Details

I. General information

NPI: 1063242691
Provider Name (Legal Business Name): BROCK A VAN GORDON DMD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6485 SW BORLAND RD STE G
TUALATIN OR
97062-9762
US

IV. Provider business mailing address

6485 SW BORLAND RD STE G
TUALATIN OR
97062-9762
US

V. Phone/Fax

Practice location:
  • Phone: 503-878-4163
  • Fax: 833-438-7620
Mailing address:
  • Phone: 503-878-4163
  • Fax: 833-438-7620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. BROCK ASHLEY VAN GORDON
Title or Position: OWNER/ DENTIST
Credential: DMD
Phone: 503-730-4924