Provider Demographics
NPI:1285966481
Name:GORDON ORTHODONTICS, INC.
Entity type:Organization
Organization Name:GORDON ORTHODONTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:401-828-1171
Mailing Address - Street 1:840 TIOGUE AVE
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:RI
Mailing Address - Zip Code:02816-5914
Mailing Address - Country:US
Mailing Address - Phone:401-828-1171
Mailing Address - Fax:401-828-4704
Practice Address - Street 1:1171 MAIN STREET
Practice Address - Street 2:
Practice Address - City:HOPE VALLEY
Practice Address - State:RI
Practice Address - Zip Code:02832
Practice Address - Country:US
Practice Address - Phone:401-828-1171
Practice Address - Fax:401-828-4704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-12
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI842039OtherUNITED CONCORDIA
RIWG00555Medicaid