Provider Demographics
NPI:1306921721
Name:GORDEEV, MIKHAIL (DDS)
Entity type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:
Last Name:GORDEEV
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 1:450 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:METUCHEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08840
Mailing Address - Country:US
Mailing Address - Phone:732-452-0222
Mailing Address - Fax:732-452-0220
Practice Address - Street 1:450 MAIN STREET
Practice Address - Street 2:
Practice Address - City:METUCHEN
Practice Address - State:NJ
Practice Address - Zip Code:08840
Practice Address - Country:US
Practice Address - Phone:732-452-0222
Practice Address - Fax:732-452-0220
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI204511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7956100Medicaid