Provider Demographics
NPI:1548482300
Name:GORDON D. GROSS, D.D.S.,P.C.
Entity type:Organization
Organization Name:GORDON D. GROSS, D.D.S.,P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:D
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-995-0280
Mailing Address - Street 1:2715 W NORTHERN AVE
Mailing Address - Street 2:#102
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-6641
Mailing Address - Country:US
Mailing Address - Phone:602-995-0280
Mailing Address - Fax:602-864-9161
Practice Address - Street 1:2715 W NORTHERN AVE
Practice Address - Street 2:#102
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-6641
Practice Address - Country:US
Practice Address - Phone:602-995-0280
Practice Address - Fax:602-864-9161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ824144OtherUNITED CONCORDIA