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General NPI Number Information
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NPI Number | 1548610926
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Entity Type | Individual
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Provider Name | MORGAN GONDER
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Gender | Male
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Dates
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Enumeration Date | 06/16/2016
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Last Update Date | 04/21/2021
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Provider Practice Location Address
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Address Line | 3615 S HOUSTON LEVEE RD STE 104
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City | COLLIERVILLE
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State | TN
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Zip | 38017-9173
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Country | US
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Telephone | 901-850-5874
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1218
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City | OXFORD
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State | MS
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Zip | 38655-1218
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Country | US
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Telephone | 662-234-4822
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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 | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 4108-20
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DS0000011182
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License Number State | TN
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