MEDICARE: KEMONE GORDON

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	124Q00000X	Dental Hygienist

General Provider Information

NPI Number	:	1730917105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEMONE GORDON

Provider Business Mailing Address
First Line	:	26159 MOUNTAIN LN
Second Line	:
City	:	EVANS MILLS
State	:	NY
Zip	:	13637-3423
Country	:	US
Telephone Number	:	757-705-0109
Fax Number	:

Provider Business Practice Location Address
First Line	:	26159 MOUNTAIN LN
Second Line	:
City	:	EVANS MILLS
State	:	NY
Zip	:	13637-3423
Country	:	US
Telephone Number	:	757-705-0109
Fax Number	:

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

Provider Enumeration Date	:	07/25/2024
Last Update Date	:	07/25/2024

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Directions to “ KEMONE GORDON ” Practice Location

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