MEDICARE: MR. SCOTT THOMAS GORDON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	19423	TX

General Provider Information

NPI Number	:	1083612071
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SCOTT THOMAS GORDON DDS

Provider Business Mailing Address
First Line	:	3905 RR 620 N
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78734-2120
Country	:	US
Telephone Number	:	512-266-1308
Fax Number	:	512-266-7024

Provider Business Practice Location Address
First Line	:	3905 RR 620 N
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78734-2120
Country	:	US
Telephone Number	:	512-266-1308
Fax Number	:	512-266-7024

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	07/08/2007

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