Healthcare Provider Details

I. General information

NPI: 1629183116
Provider Name (Legal Business Name): GORDON ERNEST GRUEN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 RIDGE LAKE BLVD SUITE 101
MEMPHIS TN
38120-9426
US

IV. Provider business mailing address

780 RIDGE LAKE BLVD SUITE 101
MEMPHIS TN
38120-9426
US

V. Phone/Fax

Practice location:
  • Phone: 901-682-8431
  • Fax: 901-682-2345
Mailing address:
  • Phone: 901-682-8431
  • Fax: 901-682-2345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberDS 1783
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: