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General NPI Number Information
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NPI Number | 1063242691
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Entity Type | Organization
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Legal Business Name | BROCK A VAN GORDON DMD, PC
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Dates
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Enumeration Date | 08/07/2024
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Last Update Date | 07/11/2025
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Provider Practice Location Address
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Address Line | 6485 SW BORLAND RD STE G
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City | TUALATIN
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State | OR
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Zip | 97062-9762
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Country | US
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Telephone | 503-878-4163
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Fax | 833-438-7620
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Provider Business Mailing Address
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Address Line | 6485 SW BORLAND RD STE G
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City | TUALATIN
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State | OR
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Zip | 97062-9762
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Country | US
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Telephone | 503-878-4163
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Fax | 833-438-7620
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Authorized Official
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Title or Position | OWNER/ DENTIST
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Name | DR. BROCK ASHLEY VAN GORDON
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Credential | DMD
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Telephone | 503-730-4924
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QS1200X
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Taxonomy Name | Sleep Disorder Diagnostic Clinic/Center
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License Number |
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License Number State |
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