MEDICARE: DR. JOHN 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	044635	NY

General Provider Information

NPI Number	:	1801999719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN GORDON D.D.S.

Provider Business Mailing Address
First Line	:	111 CARLETON AVE
Second Line	:	SUITE 1
City	:	ISLIP TERRACE
State	:	NY
Zip	:	11752-2236
Country	:	US
Telephone Number	:	631-581-3500
Fax Number	:	631-581-4723

Provider Business Practice Location Address
First Line	:	111 CARLETON AVE
Second Line	:	SUITE 1
City	:	ISLIP TERRACE
State	:	NY
Zip	:	11752-2236
Country	:	US
Telephone Number	:	631-581-3500
Fax Number	:	631-581-4723

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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