=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134311210
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGAN HELGA GORDON D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2007
-----------------------------------------------------
Last Update Date | 08/13/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 742 FM 712
-----------------------------------------------------
City | MARLIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76661-4685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-883-5561
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 742 FM 712
-----------------------------------------------------
City | MARLIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76661-4685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-883-5561
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 17280
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 17280
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------