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General NPI Number Information
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NPI Number | 1073887642
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Entity Type | Organization
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Legal Business Name | DR. ANDREA T. GORDON DDS,LLC
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Dates
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Enumeration Date | 02/29/2012
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Last Update Date | 02/29/2012
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Provider Practice Location Address
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Address Line | 1408 N KINGSHIGHWAY BLVD
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City | SAINT LOUIS
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State | MO
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Zip | 63113-1400
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Country | US
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Telephone | 314-361-6767
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Fax | 314-361-1480
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Provider Business Mailing Address
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Address Line | 1408 N KINGSHIGHWAY BLVD
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City | SAINT LOUIS
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State | MO
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Zip | 63113-1400
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Country | US
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Telephone | 314-361-6767
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Fax | 314-361-1480
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Authorized Official
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Title or Position | DENTIST
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Name | DR. ANDREA T. GORDON
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Credential | D.D.S.
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Telephone | 314-361-6767
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 013689
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License Number State | MO
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