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General NPI Number Information
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NPI Number | 1376781864
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Entity Type | Organization
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Legal Business Name | JEREMIAH D GORDON, DMD, PA
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Dates
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Enumeration Date | 01/22/2009
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Last Update Date | 01/22/2009
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Provider Practice Location Address
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Address Line | 53 WILLOW DR
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City | ST AUGUSTINE
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State | FL
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Zip | 32080-5936
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Country | US
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Telephone | 904-471-5336
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Fax |
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Provider Business Mailing Address
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Address Line | 135 JENKINS ST SUITE 105A
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-5175
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Country | US
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Telephone | 904-460-0999
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Fax |
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Authorized Official
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Title or Position | DENTIS/OWNER
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Name | DR. JEREMIAH D GORDON
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Credential | DMD
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Telephone | 904-460-0999
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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 | 16348
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License Number State | FL
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