Provider Demographics
NPI:1063594042
Name:GORDON, JAY T (DDS)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:T
Last Name:GORDON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3004 H G MOSLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-2948
Mailing Address - Country:US
Mailing Address - Phone:903-758-3444
Mailing Address - Fax:903-758-1967
Practice Address - Street 1:3004 H G MOSLEY PKWY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-2948
Practice Address - Country:US
Practice Address - Phone:903-758-3444
Practice Address - Fax:903-758-1967
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10700122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130584906Medicaid
TX89T820OtherBLUE CROSS BLUE SHIELD
TX130584906Medicaid
TX89T820Medicare ID - Type Unspecified