Provider Demographics
NPI:1902985120
Name:GORDON, JOHN JOSEPH (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JOSEPH
Last Name:GORDON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 SW VERMONT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-1939
Mailing Address - Country:US
Mailing Address - Phone:503-246-7717
Mailing Address - Fax:
Practice Address - Street 1:2425 SW VERMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-1939
Practice Address - Country:US
Practice Address - Phone:503-246-7717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR50471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice