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General NPI Number Information
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NPI Number | 1932371259
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Entity Type | Individual
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Provider Name | JEFFREY GLEN GORDON D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 03/26/2008
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Last Update Date | 02/18/2022
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Provider Practice Location Address
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Address Line | 8244 S KEDZIE AVE
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City | CHICAGO
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State | IL
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Zip | 60652-3329
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Country | US
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Telephone | 773-445-3337
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Fax | 773-445-3340
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Provider Business Mailing Address
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Address Line | PO BOX 29052
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City | CHICAGO
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State | IL
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Zip | 60629-0052
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Country | US
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Telephone | 773-445-3337
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Fax | 773-445-3340
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019023383
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License Number State | IL
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