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General NPI Number Information
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NPI Number | 1134792666
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Entity Type | Individual
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Provider Name | BRIAN KEITH GORDON DMD
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Gender | Male
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Dates
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Enumeration Date | 07/22/2021
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Last Update Date | 07/23/2024
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Provider Practice Location Address
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Address Line | 620 JOHN PAUL JONES CIR STE 275
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City | PORTSMOUTH
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State | VA
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Zip | 23708-2197
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Country | US
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Telephone | 757-953-7550
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Fax |
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Provider Business Mailing Address
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Address Line | 2054 W 1600 N
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City | PROVO
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State | UT
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Zip | 84604-2282
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Country | US
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Telephone | 801-636-1616
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 12315200-9921
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License Number State | UT
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