=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770304024
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW SPENCER GORDON DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2024
-----------------------------------------------------
Last Update Date | 10/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 HOSPITAL AVE
-----------------------------------------------------
City | DU BOIS
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15801-1439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-375-1023
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 999 TREASURE LK
-----------------------------------------------------
City | DU BOIS
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15801-9022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-751-1727
-----------------------------------------------------
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 | DS044859
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------