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General NPI Number Information
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NPI Number | 1265591382
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Entity Type | Individual
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Provider Name | MATHEW CHARLES GORDON M.D. D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 12/06/2006
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 235 E HILDEBRAND AVE
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City | SAN ANTONIO
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State | TX
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Zip | 78212-2430
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Country | US
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Telephone | 210-824-4501
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Fax | 210-824-0125
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Provider Business Mailing Address
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Address Line | 430 DEVINE RD
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City | SAN ANTONIO
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State | TX
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Zip | 78212-2527
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Country | US
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Telephone | 210-824-4501
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Fax | 210-824-0125
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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 | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | K6594
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 16834
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License Number State | TX
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