MEDICARE: DAVID MICHAEL GORDON D.D.S.

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	31465	CA

General Provider Information

NPI Number	:	1487757308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID MICHAEL GORDON D.D.S.

Provider Business Mailing Address
First Line	:	823 BANTRY COURT
Second Line	:
City	:	BENICIA
State	:	CA
Zip	:	94510
Country	:	US
Telephone Number	:	707-745-1344
Fax Number	:	707-642-7502

Provider Business Practice Location Address
First Line	:	23 ROTARY WAY
Second Line	:
City	:	VALLEJO
State	:	CA
Zip	:	94591-8475
Country	:	US
Telephone Number	:	707-557-2200
Fax Number	:	707-642-7502

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

Provider Enumeration Date	:	09/06/2006
Last Update Date	:	07/08/2007

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