Healthcare Provider Details

I. General information

NPI: 1427586775
Provider Name (Legal Business Name): RHODE ISLAND CHILDRENS DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 TIOGUE AVE
COVENTRY RI
02816-5914
US

IV. Provider business mailing address

840 TIOGUE AVE
COVENTRY RI
02816-5914
US

V. Phone/Fax

Practice location:
  • Phone: 401-828-1171
  • Fax:
Mailing address:
  • Phone: 401-828-1171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDEN03331
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberRI2421
License Number StateRI

VIII. Authorized Official

Name: DR. WILLIAM GORDON
Title or Position: OWNER
Credential: DMD
Phone: 401-828-1171